DPA-enriched compositions of omega-3 polyunsaturated fatty acids in free acid form

ABSTRACT

DPA-enriched pharmaceutical compositions of polyunsaturated fatty acids in free acid form, therapeutic methods for their use, and processes for refining the compositions from fish oil are presented.

1. CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No. 13/734,846, filed Jan. 4, 2013 (now U.S. Pat. No. 9,050,308), which claims the benefit under 35 U.S.C. § 119(e) of U.S. Provisional Application Nos. 61/583,796, filed Jan. 6, 2012; 61/664,047, filed Jun. 25, 2012; 61/669,940, filed Jul. 10, 2012; 61/680,622, filed Aug. 7, 2012; 61/710,517, filed Oct. 5, 2012; and 61/713,388, filed Oct. 12, 2012, the contents of all of which are incorporated herein by reference in their entireties.

2. BACKGROUND

Pharmaceutical compositions rich in omega-3 (“ω-3” or “n-3”) polyunsaturated fatty acids (“PUFAs”) are being developed to treat a variety of clinical indications.

These products, which are derived from natural sources, typically fish oils, are heterogeneous compositions, and comprise various species of omega-3 PUFAs, omega-6 PUFAs, and other minor components, including mono-unsaturated and saturated fatty acids. The observed clinical effects are typically attributed to the composition as a whole, although the most prevalent of the PUFA species present in the mixture, usually EPA and DHA, are believed to contribute a substantial portion of the observed clinical effect. Because they are heterogeneous compositions, the products are defined to include certain obligate polyunsaturated fatty acid species, each within a defined percentage tolerance range. The compositions are further defined to limit certain undesired components, both those originating in the natural source, such as certain environmental contaminants, and those potentially created in the refining process.

The optimal composition likely differs as among intended clinical indications. Even for the first approved clinical indication, however, treatment of severe hypertriglyceridemia (TGs>500 mg/dl), the optimal composition has not yet been defined.

Thus, the first-approved pharmaceutical composition for treatment of severe hypertriglyceridemia comprises the omega-3 PUFA species eicosapentaenoic acid (“EPA”) and docosahexaenoic acid (“DHA”) in the form of ethyl esters in weight percentages of approximately 46:38 (EPA:DHA), with EPA and DHA together accounting for approximately 84% of all PUFA species in the composition. By contrast, the more recently approved product, Vascepa® (previously known as AMR101), which is approved for the same clinical indication, is >96% pure EPA in the ethyl ester form, with substantially no DHA. The nutraceutical product, OMAX3, sold as a dietary supplement and promoted in part to lower triglyceride levels, comprises EPA and DHA in a weight ratio of about 4.1:1, wherein the EPA and DHA are likewise in the ethyl ester form, the formulation being more than 84% EPA and DHA by weight and more than 90% omega-3 fatty acids by weight.

These wide variations in composition reflect continuing uncertainty as to the optimal composition for this clinical indication.

The uncertainty is due, in part, to competing clinical goals. For example, the omega-3 PUFA species, DHA, is known to be more potent in lowering serum triglycerides than is EPA, but is known to have a greater tendency to increase LDL levels, Mori et al., Am. J. Clin. Nutr. 71:1085-94 (2000), Grimsgaard et al., Am. J. Clin. Nutr. 66:649-59 (1997); elevation of LDL has been thought to be clinically disfavored in subjects with elevated cardiovascular risk. Although decrease in platelet aggregation and thrombogenesis by omega-3 PUFAs is often clinically desired, the potential increase in bleeding time has prompted some to propose adding a certain amount of the omega-6 PUFA species, arachidonic acid (“AA”), to pharmaceutical compositions that are rich in omega-3 PUFAs. See US pre-grant publication no. 2010/0160435.

The difficulty in defining an optimal composition is also due in part to enzymatic interconversion among certain omega-3 PUFA species, and to competition between omega-3 and omega-6 polyunsaturated fatty acids for shared enzymes in their respective biosynthetic pathways from medium chain dietary PUFAs (see FIG. 1).

A further challenge in designing an optimal composition is variation in bioavailability of orally administered PUFA compositions. Absorption of PUFAs in the form of ethyl esters is known, for example, to depend on the presence of pancreatic lipase, which is released in response to ingested fats. Absorption of PUFA ethyl esters is therefore inefficient, and is subject to substantial variation, both among subjects and in any individual subject, depending on dietary intake of fat. See Lawson et al., “Human absorption of fish oil fatty acids as triacylglycerols, free acids, or ethyl esters,” Biochem Biophys Res Commun. 152:328-35 (1988); Lawson et al., Biochem Biophys Res Commun. 156:960-3 (1988). Absorption is particularly reduced in subjects on low-fat diets, a diet advocated for subjects with elevated serum triglyceride levels or cardiovascular disease.

For any specifically desired PUFA pharmaceutical composition, the refining process is designed to produce a final product having the obligate fatty acid components within pre-defined percentage tolerance ranges and to limit certain undesired components to levels below certain pre-defined tolerance limits, with sufficient yield to make the process commercially feasible and environmentally sustainable. Differences in the desired final composition dictate differences in the refining process.

Various known process steps present trade-offs that make composition-specific adaptation and optimization of the refining process difficult, however. For example, urea inclusion complexation (clathration) in the presence of ethanol is often used to remove saturated and mono-unsaturated long chain fatty acids, increasing the relative proportion of desired long chain omega-3 polyunsaturated fatty acids in the resulting composition. Too little urea reduces long chain omega-3 PUFA enrichment. Excess urea, however, can lead to concentration of unwanted components, and has the potential to lead, at any given temperature and reaction time, to increased production of ethyl carbamate, a carcinogen that is impermissible above certain defined low limits. Existing alternatives to urea complexation, however, present other difficulties.

There is, therefore, a need for improved pharmaceutical compositions rich in omega-3 polyunsaturated fatty acids, especially for treatment of hypertriglyceridemia and mixed dyslipidemias, and for improved processes for refining such compositions from fish oil.

3. SUMMARY

In a first aspect, the present disclosure provides DPA-enriched pharmaceutical compositions of omega-3 polyunsaturated fatty acids in free acid form. Enrichment in DPA content was an unintended and unexpected consequence of the commercial-scale production process. These DPA-enriched pharmaceutical compositions have been demonstrated to have exceptional pharmacological and clinical efficacy in in vitro experiments and in human clinical trials.

Accordingly, in another aspect, methods of treatment are provided. In one series of treatment embodiments, methods of treating severe hypertriglyceridemia (TGs>500 mg/dL) are provided. In another series of treatment embodiments, methods of treating hypertriglyceridemia (200 mg/dL-500 mg/dL) by adjunctive administration of a statin and the pharmaceutical compositions described herein are provided. Further treatment methods include, inter alia, treatments to increase plasma EPA:AA ratios, treatments to decrease ApoCIII levels, and treatments to reduce or prevent resistance to platelet aggregation inhibitors.

Also disclosed herein are methods of making the pharmaceutical compositions at commercial scale, including methods that include a urea complexation step in which compositionally-constrained batches of transesterified intermediate feedstock are subjected to a urea complexation step using urea amounts within ranges determined by a new process algorithm.

4. BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows the known human pathways for biosynthesis of omega-3 and omega-6 long-chain polyunsaturated fatty acids from intermediate (medium) chain length essential fatty acids.

FIG. 2 is flow chart of an exemplary process for preparing an intermediate feedstock of PUFA ethyl esters.

FIG. 3A plots the average relative purification of classes of fatty acids by a urea complexation step in which algorithmically-determined amounts of urea are added to compositionally-defined intermediate feedstock of PUFA ethyl esters.

FIG. 3B illustrates the average differential purification of individual species of omega-3 and omega-6 PUFA ethyl esters when algorithmically-determined amounts of urea are added to compositionally-defined intermediate feedstock of PUFA ethyl esters.

FIG. 4 is a treatment flow diagram illustrating the design of the ECLIPSE clinical study further described in Example 7.

FIG. 5 compares the bioavailability of total EPA+DHA (baseline-adjusted change) following a single dose (4 g) of Lovaza® during the high-fat and low-fat diet periods.

FIG. 6 compares the bioavailability of total EPA+DHA (baseline-adjusted change) following a single dose (4 g) of Lovaza® (“EE-FA”) or Epanova®, a DPA-enriched composition of omega-3 PUFAs in free acid form (“FFA”), during the high-fat diet period.

FIG. 7 compares the total plasma EPA+DHA concentrations (baseline-adjusted change) following a single dose (4 g) of Lovaza® or Epanova® during the low-fat diet period.

FIG. 8 compares the total plasma EPA concentrations (baseline-adjusted change) following a single dose (4 g) of Lovaza® or Epanova® during the low-fat diet period.

FIG. 9 compares the total plasma DHA concentrations (baseline-adjusted change) following a single dose of (4 g) of Lovaza® or Epanova® during the low-fat diet period.

FIGS. 10A and 10B present individual subject AUC_(0-t) responses during the low-fat and high-fat diets expressed as the ratio (%) of low-fat AUC_(0-t) to high-fat AUC_(0-t). Negative ratios were not plotted.

FIG. 11 is a treatment flow diagram illustrating the design of the 14 day comparative bioavailability trial further described in Example 8 (timeline not to scale).

FIG. 12A plots the mean unadjusted total EPA+DHA concentrations versus time (linear scale) for treatment with Lovaza® vs. treatment with Epanova® in the 14 day comparative bioavailability trial further described in Example 8.

FIG. 12B is a histogram showing the difference in unadjusted EPA+DHA (nmol/mL) for the points bracketed in FIG. 12A.

FIG. 13 plots EPA+DHA mean base-line adjusted plasma total EPA+DHA concentrations versus time (linear scale) for treatment with Lovaza® vs. treatment with Epanova® in the 14 day comparative bioavailability study.

FIG. 14A is a histogram that plots the increases from baseline to steady state in unadjusted blood levels for EPA+DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study.

FIG. 14B is a histogram that plots the increases from baseline to steady state in unadjusted C_(avg) for EPA+DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study.

FIG. 15A is a histogram that plots the increases from baseline to steady state for total blood levels of DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study.

FIG. 15B is a histogram that plots the increases from baseline to steady state for DHA C_(avg) levels in the Epanova® cohort compared to Lovaza® cohort in the 14 day comparative bioavailability study.

FIG. 16A is a histogram that plots the increases from baseline to steady state for total EPA levels in blood in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study.

FIG. 16B plots the increases from baseline to steady state for EPA C_(avg) levels in the Epanova® and Lovaza® cohorts in the 14 day comparative bioavailability study.

FIG. 17 provides a treatment flow diagram illustrating the design of the EVOLVE study, further described in Example 10.

FIG. 18 summarizes the EVOLVE trial design in greater detail, further identifying the timing of study visits.

FIG. 19 shows the disposition of subjects in the EVOLVE trial.

FIGS. 20A-20D display average baseline and end-of-treatment (“EOT”) plasma levels (in μg/mL) for EPA (FIG. 20A), DHA (FIG. 20B), DPA (FIG. 20C) and AA (FIG. 20D), for each of the treatment arms in the EVOLVE trial.

FIG. 20E compares average baseline and EOT EPA levels for the ECLIPSE trial described in Example 7, the 14-day bioavailability study described in Example 8, a statin drug-drug interaction study (“STATIN DDI”) described in Example 11, each treatment arm as well as the control arm of the EVOLVE trial described in Example 10, and values earlier reported in the literature for the unrelated JELIS trial (“JELIS”), which used a different omega-3 composition.

FIGS. 21A-21D plot median baseline and end-of-treatment (“EOT”) plasma levels (in μg/mL) for EPA (FIG. 21A), DHA (FIG. 21B), DPA (FIG. 21C), and AA (FIG. 21D) in the EVOLVE trial.

FIGS. 22A and 22B plot change from baseline to EOT in absolute plasma levels (in μg/mL) of AA, DHA, EPA, and DPA, for each of the treatment arms of the EVOLVE trial. FIG. 22A plots average changes; FIG. 22B plots median changes.

FIG. 23A plots average change from baseline to EOT, as percentage of baseline value, for AA, DHA, EPA, and DPA in each of the treatment arms of the EVOLVE trial. FIG. 23B plots median percent change from baseline to EOT.

FIGS. 24A-24I plot average baseline and EOT plasma levels (in mg/dL, with the exception of LpPLA2, shown in ng/mL) in the EVOLVE trial for triglycerides (FIG. 24A), Non-HDL-C (FIG. 24B), HDL-C (FIG. 24C), V-LDL-C (FIG. 24D), LDL-C (FIG. 24E), ApoB (FIG. 24F), ApoCIII (FIG. 24G), RLP (FIG. 24H), LpPLA2 (FIG. 24I).

FIGS. 25A-25I plot median baseline and EOT plasma levels (in mg/dL, with the exception of LpPLA2, shown in ng/mL) in the EVOLVE trial for triglycerides (FIG. 25A), Non-HDL-C (FIG. 25B), HDL-C (FIG. 25C), V-LDL-C (FIG. 25D), LDL-C (FIG. 25E), ApoB (FIG. 25F), ApoCIII (FIG. 25G), RLP (FIG. 25H), LpPLA2 (FIG. 25I).

FIGS. 26A and 26B plot change from baseline to EOT in absolute plasma levels (in mg/dL) in the EVOLVE trial of triglycerides (“TG”), Non-HDL-C (“NHDL-C”), HDL-C, VLDL-C, and LDL-C for each of the treatment arms of the EVOLVE trial, with FIG. 26A plotting average change and FIG. 26B showing median change.

FIG. 27 plots the percentage of subjects in the EVOLVE trial, given by the Y-axis, for whom triglyceride levels were reduced by the indicated percentage, given by the X-axis, for 2 g dose and 4 g dose of Epanova®.

FIG. 28A plots average change from baseline to EOT, as percentage of baseline value, for TG, non-HDL-c (“NHDL-C”), HDL-C, VLDL-C, LDL-C, ApoB, ApoCIII, LpLPA2, and RLP in each of the treatment arms of the EVOLVE trial, with FIG. 28B plotting median percent change from baseline to EOT.

FIG. 29 plots the rate of change (absolute value) of the median percentage change from baseline in plasma levels of EPA, DHA, DPA, AA, TG, NHDL-C, and HDL-C between 2 g and 4 g doses of Epanova® in the EVOLVE trial.

FIG. 30 illustrates comparative data for Epanova®, as measured in the EVOLVE trial, and data reported by others for AMR-101 (Vascepa), at the indicated doses, with respect to TG levels.

FIG. 31 illustrates comparative data for Epanova®, as measured in the EVOLVE trial, and AMR-101 (Vascepa), with respect to various blood lipid parameters. Data for AMR-101 were reported by others. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 32 illustrates comparative data for Epanova® 2 g and 4 g doses, as determined in the EVOLVE trial, and Lovaza® 4 g dose, with respect to various blood lipid parameters. Data for Lovaza® were reported by others. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 33 illustrates comparative data for Epanova® 2 g and 4 g doses, as assessed in the EVOLVE trial, and Lovaza® 4 g dose, as reported by others, with respect to TG levels. The superscripts indicate data sourced from (1) EVOLVE trial, (2) a meta-analysis from the Lovaza® New Drug Application (“NDA”) (3) Lovaza® FDA-approved product Label and (4) Takeda study. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 34 plots the correlation between percent change in LDL and percent change in ApoCIII, as measured in the EVOLVE trial.

FIG. 35 plots the least squares (LS) mean percentage change from baseline for the subset of EVOLVE trial subjects having TG baseline levels greater than or equal to 750 mg/dL, for the indicated treatment arms of the EVOLVE study, as further described in Example 10. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 36 plots the least squares (LS) mean percentage change from baseline for the subset of subjects having Type II diabetes, for the indicated treatment arms of the EVOLVE study, as described in Example 10. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 37 plots the least squares (LS) mean percentage change from baseline for the subset of subjects undergoing concurrent statin therapy, for the indicated treatment arms of the EVOLVE study, as described in Example 10. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 38 plots the least squares (LS) mean percentage difference relative to control for triglycerides (“TG”), non-HDL-cholesterol (“NHDL-C”), HDL-C, LDL-C, TC, VLDL-C, and TC/HDL-C, comparing subjects from the EVOLVE study described in Example 10 who either received (STATIN) or did not receive (NON-STATIN) statin therapy concurrent with treatment with the 2 g dose of Epanova®. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 39 plots the median percent change from baseline for TG, NHDL-C, HDL-C, LDL-C, TC, VLDL-C, and TC/HDL-C for the subset of subjects undergoing concurrent statin therapy, in the indicated treatment arms of the EVOLVE study, further described in Example 10. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 40 provides a treatment flow diagram illustrating the design of the ESPRIT study, further described in Example 12.

FIG. 41 shows the disposition of subjects in the ESPRIT trial.

FIGS. 42A and 42B plot the median LS percentage change from baseline for EPA (FIG. 42A) and DHA (FIG. 42B) from the ESPRIT study, further described in Example 12. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 43 plots mean LS percentage change from baseline for TG, Non-HDL-C, and HDL-C. Data shown are from the ESPRIT study, further described in Example 12. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 44 plots mean LS percentage change from baseline for ApoB, LDL-C, VLDL-C, and TC/HDL-C. Data shown are from the ESPRIT study, further described in Example 12. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 45 plots median percentage change from baseline for TG, with subjects grouped into tertiles by baseline TG levels, for subjects in the ESPRIT trial.

FIG. 46 plots median percentage change from baseline for Non-HDL-C, with subjects grouped into tertiles by baseline Non-HDL-C levels, for subjects in the ESPRIT trial.

FIG. 47 plots median percentage change from baseline for LDL-C, with subjects grouped into tertiles by baseline LDL-C levels, for subjects in the ESPRIT trial.

FIG. 48 plots median percentage change from baseline for TG for each of the treatment arms of the ESPRIT trial, with subjects grouped according to the identity of the statin taken in concurrent therapy.

FIG. 49 plots median percentage change from baseline for TG for each of the treatment arms of the ESPRIT trial, with subjects grouped into two groups according to low or high potency concurrent statin therapy.

FIG. 50 plots median percentage change from baseline for Non-HDL-C for each of the treatment arms of the ESPRIT trial, with subjects grouped according to low or high potency concurrent statin therapy.

FIG. 51 plots median percentage change from baseline for LDL-C for each of the treatment arms of the ESPRIT trial, with subjects grouped into two groups according to low or high potency concurrent statin therapy.

FIG. 52 plots median percentage change from baseline for TG, with subjects in each treatment arm of the ESPRIT trial grouped into three groups according to high baseline TG, high baseline EPA, or concurrent rosuvastatin therapy.

FIG. 53 plots mean LS percentage change in particle size distribution from baseline for V-LDL particles grouped by size, as determined in the ESPRIT trial. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 54 plots mean LS percentage change in particle size distribution from baseline for LDL particles grouped by size for each of the treatment arms of the ESPRIT trial. (*) indicates a p value of less than 0.05, (**) indicates a p value of less than 0.01, and (***) indicates a p value of less than 0.001.

FIG. 55 plots LS median percentage change in LDL particle size, with subjects grouped into three groups according to ESPRIT EOT triglyceride levels.

FIG. 56A depicts baseline arachidonic acid (AA) plasma levels (in μg/mL) for subjects in the clinical trial further described in Example 11, grouped according to genotype at the rs174546 SNP. FIG. 56B depicts percent change from baseline in AA plasma levels at day 15 of treatment with Epanova®, grouped according to genotype at the rs174546 SNP. For each genotype, the interquartile range is indicated by a box, the median is indicated by a horizontal line in the interior of the interquartile box, and the mean is represented by a diamond. Outliers are represented by open circles. The whiskers extend to the minimum and maximum non-outlier value. Score 1 identifies subjects who are homozygous at the major allele; Score 3 identifies subjects homozygous at the minor allele; and Score 2 represents heterozygotes.

5. DETAILED DESCRIPTION 5.1. Overview: Pharmaceutical Compositions of Omega-3 Polyunsaturated Fatty Acids in Free Acid Form that are Unexpectedly Enriched in DPA have Exceptional Clinical Efficacy

Urea inclusion complexation (clathration) is a standard step often used in the refining of fish oils to remove saturated and mono-unsaturated long chain fatty acids, thus enriching for desired long chain omega-3 polyunsaturated fatty acids in the resulting composition. Despite long usage, however, and studies designed to characterize the effects of various physiochemical parameters on the process, the degree to which urea complexation enriches individual species of long chain polyunsaturated fatty acids remains unpredictable. This residual unpredictability in the urea complexation procedure, coupled with the potential for generating impermissibly high levels of ethyl carbamate, which would obligate additional processing, initially militated in favor of omitting urea complexation from the commercial scale refining process to be used for producing pharmaceutical grade compositions of omega-3 PUFAs in free acid form meeting certain desired compositional specifications.

However, as further described in Example 1, early efforts to develop a urea-free commercial scale process made clear that such processes could not reliably produce batches with a composition that met required specifications. Accordingly, a process using urea complexation was sought, and it was discovered that strict compositional control on the PUFA species present in the intermediate ethyl ester feedstock, coupled with use of an algorithmically-determined amount of urea, could reliably produce batches meeting the required specifications, and without exceeding acceptable ethyl carbamate limits.

As described in Example 2, four exemplary production batches of polyunsaturated fatty acids in free acid form were prepared using a urea complexation step. Strict compositional controls were applied to the ethyl ester intermediate feedstock, using only batches in which specified species of polyunsaturated fatty acids fell within defined range limits, and urea amounts were used that fell within the range required by the urea calculator algorithm. All four production batches of the pharmaceutical composition were determined to meet the desired compositional specifications.

As expected, the urea complexation step substantially decreased the percentage of saturated fatty acids and mono-unsaturated fatty acids in the resulting composition, thereby substantially enriching for polyunsaturated fatty acids. See FIG. 3A. Unexpectedly, however, performing urea complexation using urea amounts falling within the algorithmically-determined range had differential effects on enrichment of particular species of omega-3 polyunsaturated fatty acids and omega-6 polyunsaturated fatty acids.

As described below in Example 3, the omega-3 docosapentaenoic acid species, DPA (C22:5 n-3), was found to be enriched, whereas the corresponding omega-6 species, with identical chain length and degree of unsaturation, docosapentaenoic acid (C22:5 n-6), was reduced in prevalence. The divergent effect of urea complexation on enrichment of these two isomers—in conjunction with differences in their relative concentrations in the ethyl ester intermediate feed stock—resulted in a log order difference in their concentrations in the final, free acid, pharmaceutical composition (“API”).

Further production batches were prepared, and as described in Example 4, compositional analysis of 10 batches of API demonstrated reproducibly elevated levels of DPA in the final composition. As described in Example 5, compositional analysis of 21 batches prepared using urea complexation demonstrated a reproducible 10-fold difference in the concentration of the omega-3 species, DPA, as compared to its omega-6 isomer, docosapentaenoic acid (C22:5 n-6).

At an average concentration of 4.44% (a/a) across 21 production batches, DPA is the third most prevalent species of polyunsaturated fatty acid in the API, exceeded only by EPA and DHA. At this level, the DPA concentration is also approximately 10-fold greater than that reported for an earlier pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form, termed Purepa, in which DPA was reported to be present at a level of 0.5%. See Belluzzi et al., Dig. Dis. Sci. 39(12): 2589-2594 (1994).

Although DPA is an intermediate in the biosynthetic pathway from EPA to DHA (see FIG. 1), surprisingly little is known about the DPA's specific biological effects. To clarify the potential contribution of DPA to clinical efficacy of the pharmaceutical composition, gene expression profiling experiments were conducted using HepG2 hepatocarcinoma cells.

As further described in Example 6, DPA's effects on hepatic cell gene expression predict greater clinical efficacy of DPA-enriched compositions.

The gene expression profiling experiments demonstrated that DPA has significant biological activity at relevant in vitro concentrations. These effects are markedly different from those seen with EPA and with DHA.

At relevant concentration, DPA was observed to affect expression of genes in multiple metabolic pathways, including genes in categories known to be relevant to the clinical effects of omega-3 polyunsaturated fatty acids: genes involved in lipid metabolism, genes involved in cardiovascular physiology, and genes involved in inflammation. Significant second-order effects are also predicted, given the changes observed in the expression of genes that encode proteins that themselves affect gene expression, and in genes encoding proteins that affect post-transcriptional modification.

Specific effects on expression of several genes involved in lipid metabolism suggest that DPA, at an analogous in vivo concentration, should contribute to improvement in various clinically-relevant lipid parameters. In particular, the observed DPA-driven upregulation of ACADSB, the short/branched chain acyl-CoA dehydrogenase, predicts lower serum triglyceride levels; DPA-driven downregulation of HMGCR, analogous to inhibition of the encoded HMG-CoA-reductase enzyme by statins, would be predicted to lead to favorable decreases in the total cholesterol:HDL ratio; and DPA downregulation of SQLE, a rate-limiting step in sterol synthesis, analogously predicts reductions in total cholesterol levels.

The expression profiling experiments also demonstrated a dose threshold for DPA's effects. The lower concentration tested, chosen to mimic the 10-fold lower concentration of DPA in the earlier free acid omega-3 formulation, Purepa, affected the expression of 10-fold fewer genes than the higher DPA concentration, chosen to mimic the exposure expected from the pharmaceutical compositions described herein, demonstrating that the lower DPA concentration provides subthreshold exposure, and would be expected to provide a subtherapeutic dose in vivo.

Human clinical trials confirmed the exceptional clinical efficacy of the DPA-enriched pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form.

Example 7 presents the results of the ECLIPSE clinical trial, an open-label, single dose, randomized 4-way-crossover study comparing the bioavailability of a 4 g dose of Lovaza® to bioavailability of a 4 g dose of the DPA-enriched pharmaceutical composition of omega-3 PUFA in free acid form described herein (hereinafter, “Epanova®”), under both high fat and low fat dietary conditions. According to the FDA-approved product label, each 1-gram capsule of Lovaza® contains at least 900 mg of the ethyl esters of omega-3 fatty acids sourced from fish oils, predominantly a combination of ethyl esters of eicosapentaenoic acid (EPA—approximately 465 mg) and docosahexaenoic acid (DHA—approximately 375 mg). The batch of Epanova® used in the trial comprised 57.3% (a/a) EPA, 19.6% (a/a) DHA, and 6.2% (a/a) DPA, each substantially in free acid form.

The baseline-adjusted change in total EPA+DHA and individual EPA and DHA absorption profiles (AUC) with Epanova® (omega-3 PUFAs in free acid form) were significantly greater than with Lovaza® (omega-3-PUFA ethyl esters) during the high-fat diet period and dramatically better during the low-fat diet period. Furthermore, there was a profound impact of fat content of the meals on the bioavailability of Lovaza®, whereas the bioavailability of Epanova® was much more predictable, due to only modest food effect.

The superior fat-independent bioavailability of Epanova® over Lovaza® is clinically important, in view of the NCEP ATP III recommendation that subjects with hypertriglyceridemia and dyslipidemias adhere to a low-fat diet during adjunct therapy.

Example 8 presents results from a 14-day bioavailability study, which demonstrated that the increase in bioavailability observed in the single-dose ECLIPSE trial is maintained, even enhanced, over 2 weeks of dosing. In addition, disaggregated subject-specific data demonstrated that the subject with least response to Epanova® still had a greater day-14 EPA+DHA C_(max) than the subject with best response to Lovaza®.

Example 10 presents the results of the EVOLVE trial, a 12-week, double-blind, olive oil-controlled study of patients selected on the basis of high triglyceride levels, in the range of 500-2,000 mg/dL (severe hypertriglyceridemia). The primary study endpoint was percent change in plasma triglyceride levels from baseline to end-of-treatment (“EOT”). The secondary endpoint was percent change in plasma non-HDL cholesterol (“non-HDL-C”) from baseline to EOT.

As can be seen from FIGS. 20-23, 12 week treatment with Epanova® caused dramatic increases in plasma levels of EPA, DHA, and DPA.

Increases in plasma levels of EPA, DHA, and DPA were accompanied by significant reductions in plasma AA levels, with the 4 g dosage regimen effecting an average reduction of 18%, a median reduction of 25.9%, and a least squares (“LS”) mean reduction of 23.2%. These decreases in plasma arachidonic acid levels were observed despite the administration of exogenous arachidonic acid, which was present at 2.446% (a/a) in the Epanova® batch used in this trial.

The increase in EPA plasma levels with concomitant reduction in AA plasma levels caused a significant improvement in the EPA/AA ratio, from approximately 0.10 at baseline to approximately 0.67 (average) and 0.62 (median) at end-of-treatment (“EOT”) at the 4 g dose. The EPA/AA ratio has been reported to constitute an independent risk factor for coronary atherosclerosis, Nakamua & Maegawa, Endocrine Abstracts (2012) 29 OC19.1, with lower ratios associated with progression in coronary atherosclerosis in statin-treated patients with coronary artery disease, Nozue et al., Am J Cardiol. 2013 Jan. 1; 111(1):6-1 (ePub ahead of print).

Furthermore, treatment with Epanova® resulted in substantial reductions in triglyceride levels (see FIGS. 26A and 26B), reductions in non-HDL-C and VLDL-C, and increase in HDL-C. LDL-C levels were elevated, an observation that may be attributed to an increase in LDL particle size upon treatment (discussed further in Example 12).

The EVOLVE trial also demonstrated that Apolipoprotein CIII (ApoCIII) was significantly reduced by Epanova® treatment. Elevated levels of ApoCIII have been found to be an independent predictor for cardiovascular heart disease (CHD) risk, whereas genetically reduced levels of ApoCIII have been associated with protection from CHD, and have also been correlated with increase in longevity.

The extremely high bioavailability of the omega-3 PUFAs in Epanova® revealed previously unknown, and unexpected, differences in pharmacokinetic response among the various PUFA species.

FIG. 29 plots the rate of change in the median percentage change from baseline in plasma levels of EPA, DHA, DPA, AA, TG, non-HDL-C, and HDL-C (absolute value) between 2 g and 4 g doses of Epanova®. With little or no increase in plasma levels of DHA and DPA upon doubling of the Epanova® dose from 2 g to 4 g per day, the rate of change (slope) in the median percentage change from baseline is near zero, predicting little further increase in DHA and DPA plasma levels would be achieved if dose is further increased. Similar plateauing of response was seen in triglyceride levels, HDL-C levels, and non-HDL-C levels (data not shown).

By contrast, the rate of change for EPA remains high, with a slope of 0.59; further increase in EPA plasma levels is expected to be obtained by increasing Epanova® dosage above 4 g per day. Significantly, the rate of change (decrease) in AA levels upon doubling the Epanova® dose from 2 g to 4 g per day is even higher than that for EPA; further reductions in AA plasma levels are expected as Epanova® dosage is increased above 4 g/day. Epanova® thus exhibits unprecedented potency in ability to elevate EPA levels, reduce AA levels, and improve the EPA:AA ratio.

As shown in FIG. 38, a subset of subjects in the 2 g treatment arm of the EVOLVE trial who were receiving concurrent statin therapy displayed greater magnitudes of percentage changes (mean LS difference), relative to control, for TG, non-HDL-C, HDL-C, LDL-C, TC, VLDL-C, and TC/HDL-C, when compared to those subjects in the 2 g treatment arm who did not receive concurrent statin therapy. Subjects receiving concurrent statin therapy showed a dose-dependent response to Epanova®, as shown in comparative data for Epanova® 2 g and Epanova® 4 g displayed in FIG. 39.

Example 12 describes the ESPRIT clinical trial, which was conducted to study patients on baseline statin therapy with triglyceride levels between 200-500 mg/dL, lower than the patients with severe hypertriglyceridemia enrolled in the EVOLVE study described in Example 10.

Dose-dependent reductions in triglycerides, reductions in non-HDL-C, and increases in HDL-C, were observed, when compared to olive oil placebo (see FIG. 43). Furthermore, dose-dependent reductions in VLDL-C and TC/HDL-C were observed (see FIG. 44). Taken together, the results (summarized in FIGS. 42-44) demonstrate efficacy of Epanova® as an add-on to statin therapy in patients with triglyceride levels between 200-500 mg/dL.

FIGS. 45-52 illustrate that Epanova® is efficacious as an add-on to both low-potency and high-potency statins, in a range of baseline patient conditions. As seen from FIG. 48, the reductions in TG levels were observed for patients who received concurrent rosuvastatin, atorvastatin, and simvastatin therapy. Statistically significant effects on triglycerides, non-HDL-C, and LDL-C levels were observed regardless whether low potency or high potency statins were co-administered, as shown in FIGS. 49-51.

5.2. DPA-Enriched Omega-3 Compositions in Free Acid Form

Accordingly, in a first aspect, improved compositions of polyunsaturated fatty acids (“PUFAs”) in free acid form are provided. In various embodiments, the composition is a pharmaceutical composition suitable for oral administration. In a variety of embodiments, the composition is a neutraceutical composition suitable for oral administration.

The composition comprises a plurality of species of omega-3 PUFA, each present substantially in free acid form.

The composition comprises eicosapentaenoic acid (C20:5 n-3) (“EPA,” also known as timnodonic acid), docosahexaenoic acid (C22:6 n-3) (“DHA,” also known as cervonic acid), and docosapentaenoic acid (C22:5 n-3) (“DPA”, also known as clupanodonic acid), each substantially in free acid form.

The composition comprises EPA in an amount, calculated as a percentage by area on GC chromatogram of all fatty acids in the composition, of at least about 45% (“45% (a/a)”). In various embodiments, the composition comprises EPA in an amount of at least about 46% (a/a) 47% (a/a), 48% (a/a), 49% (a/a), or at least about 50% (a/a). In certain embodiments, the composition comprises EPA in an amount of at least about 51% (a/a), at least about 52% (a/a), at least about 53% (a/a), at least about 54% (a/a), at least about 55% (a/a), at least about 56% (a/a), at least about 57% (a/a), at least about 58% (a/a), even at least about 59% (a/a), at least about 60% (a/a), at least about 61% (a/a), 62% (a/a), 63% (a/a), 64% (a/a), or 65% (a/a).

In certain embodiments, the composition comprises EPA in an amount of about 45 to about 65% (a/a). In particular embodiments, EPA is present in an amount of about 50 to about 60% (a/a). In various embodiments, EPA is present in an amount of about 52 to about 58.0% (a/a). In some embodiments, EPA is present in an amount of about 55% (a/a) to about 56% (a/a). In some embodiments, EPA is present in an amount of about 55% (a/a).

In various embodiments, the composition comprises EPA in an amount, calculated as a percentage by mass of all fatty acids in the composition (“% (m/m)”), of about 50% (m/m) to about 60% (m/m). In certain embodiments, EPA is present in an amount of about 55% (m/m).

The composition comprises DHA in an amount of at least about 13% (a/a). In various embodiments, the composition comprises DHA in an amount of at least about 14% (a/a), at least about 15% (a/a), at least about 16% (a/a), at least about 17% (a/a), at least about 18% (a/a), at least about 19% (a/a), or at least about 20% (a/a). In selected embodiments, the composition comprises DHA in an amount of at least about 21% (a/a), at least about 22% (a/a), at least about 23% (a/a), at least about 24% (a/a), even at least about 25% (a/a).

In various embodiments, the composition comprises DHA in an amount of about 13% (a/a) to about 25% (a/a). In certain embodiments, DHA is present in an amount of about 15% (a/a) to about 25% (a/a). In several embodiments, DHA is present in an amount of about 17% (a/a) to about 23% (a/a). In certain embodiments, DHA is present in an amount of about 19% (a/a) to about 20% (a/a).

In various embodiments, the compositions comprise DHA in an amount of about 15% (m/m) to about 25% (m/m). In certain embodiments, DHA is present in an amount of about 17% (m/m) to about 23% (m/m). In certain embodiments, DHA is present in an amount of about 20% (m/m).

The composition comprises DPA in an amount of at least about 1% (a/a). In various embodiments, the composition comprises DPA in an amount of at least about 1.5% (a/a), 2% (a/a), 2.5% (a/a), 3% (a/a), 3.5% (a/a), 4% (a/a), 4.5% (a/a), even at least about 5% (a/a). In selected embodiments, the composition comprises DPA in an amount of at least about 6% (a/a), at least about 7% (a/a), at least about 8% (a/a), or at least about 9% (a/a).

In a variety of embodiments, the composition comprises DPA in an amount of about 1% (a/a) to about 8% (a/a). In certain embodiments, the composition comprises DPA in an amount of about 2% (a/a) to about 7% (a/a). In selected embodiments, the composition comprises DPA in an amount of about 3% (a/a) to about 6% (a/a). In particular embodiments, the composition comprises DPA in an amount of about 4% (a/a) to about 5% (a/a).

In various embodiments, the composition comprises DPA, calculated as a percentage by mass of all fatty acids in the composition, in an amount of no less than about 1% (m/m). In various embodiments, the composition comprises DPA in an amount of about 1% (m/m) to about 8% (m/m). In particular embodiments, the composition comprises DPA in an amount of no more than about 10% (m/m).

The composition comprises EPA and DHA in a total amount of at least about 60% (a/a). In various embodiments, the composition comprises EPA and DHA in a total amount of at least about 61% (a/a), 62% (a/a), 63% (a/a), 64% (a/a), 65% (a/a), 66% (a/a), 67% (a/a), 68% (a/a), 69% (a/a), or at least about 70% (a/a). In particular embodiments, the composition comprise EPA and DHA in a total amount off at least about 71% (a/a), 72% (a/a), 73% (a/a), 74% (a/a), 75% (a/a), 76% (a/a), 77% (a/a), 78% (a/a), 79% (a/a), even at least about 80% (a/a). In certain embodiments, the composition comprises EPA and DHA in total amount of at least about 81% (a/a), 82% (a/a), at least about 83% (a/a), 84% (a/a), even at least about 85% (a/a).

In various embodiments, the composition comprises EPA and DHA in an amount of about 70.0% (m/m) to about 80.0% (m/m). In certain embodiments, the composition comprises about 75% (m/m) EPA plus DHA.

The composition comprises EPA, DHA, and DPA in a total amount of at least about 61% (a/a). In typical embodiments, the composition comprises EPA, DHA, and DPA in a total amount of at least about 62% (a/a), 63% (a/a), 64% (a/a), 65% (a/a), 66% (a/a), at least about 67% (a/a), at least about 68% (a/a), at least about 69% (a/a), or at least about 70% (a/a). In certain embodiments, the composition comprises EPA, DHA, and DPA in a total amount of at least about 71% (a/a), 72% (a/a), 73% (a/a), 74% (a/a), 75% (a/a), 76% (a/a), 77% (a/a), 78% (a/a), 79% (a/a), 80% (a/a), even at least about 81% (a/a), 82% (a/a), 83% (a/a), 84% (a/a), 85% (a/a), 86% (a/a), 87% (a/a), even at least about 88% (a/a).

In various embodiments, the composition comprises EPA, DHA, and DPA in a total amount of between about 70% (a/a) to about 90% (a/a).

In a particular series of embodiments, EPA is present in an amount of about 55% (a/a) to about 56% (a/a); DHA is present in an amount of about 19% (a/a) to about 20% (a/a); and DPA is present in an amount of about 4% (a/a) to about 5% (a/a).

In certain embodiments, the composition further comprises one or more omega-3 polyunsaturated fatty acid species selected from the group consisting of: α-linolenic acid (C18:3 n-3), moroctic acid (C18:4 n-3, also known as stearidonic acid), eicosatrienoic acid (C20:3 n-3), eicosatetraenoic acid (C20:4 n-3), and heneicosapentaenoic acid (C21:5 n-3).

In particular embodiments, the composition comprises EPA, DHA, DPA, and moroctic acid, each substantially in the free acid form. In a variety of embodiments, the composition comprises EPA, DHA, DPA, moroctic acid, and heneicosapentaenoic acid, each substantially in the free acid form. In specific embodiments, the composition comprises EPA, DHA, DPA, moroctic acid, heneicosapentaenoic acid, and eicosatetraenoic acid, each substantially in the free acid form. In selected embodiments, the composition comprises EPA, DHA, DPA, α-linolenic acid (C18:3 n-3), moroctic acid (C18:4 n-3), eicosatrienoic acid (C20:3 n-3), eicosatetraenoic acid (C20:4 n-3), and heneicosapentaenoic acid (C21:5 n-3).

In various embodiments, total omega-3 fatty acids—defined as the sum of alpha-linolenic acid (C18:3 n-3), moroctic acid (C18:4 n-3), eicosatrienoic acid (C20:3 n-3), eicosatetraenoic acid (C20:4 n-3), eicosapentaenoic acid (EPA) (C20:5 n-3), heneicosapentaenoic acid (C21:5 n-3), docosapentaenoic acid (C22:5 n-3) and docosahexaenoic acid (DHA) (C22:6 n-3)—constitute from about 80% (a/a) to about 95% (a/a) of all fatty acids in the composition. In a variety of embodiments, total omega-3 fatty acids constitute from about 80-about 95% (m/m) of all fatty acids in the composition.

In various embodiments, the composition further comprises one or more species of omega-6 PUFA, each present substantially in the free acid form.

In certain embodiments, the composition comprises one or more species of omega-6 PUFA selected from the group consisting of linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3 n-6), eicosadienoic acid (C20:2 n-6), dihomo-gamma-linolenic acid (C20:3 n-6) (“DGLA”), arachidonic acid (C20:4 n-6) (“AA”), and docosapentaenoic acid (C22:5 n-6, also known as osbond acid).

In particular embodiments, the composition comprises linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3 n-6), eicosadienoic acid (C20:2 n-6), dihomo-gamma-linolenic acid (C20:3 n-6) (“DGLA”), arachidonic acid (C20:4 n-6) (“AA”), and docosapentaenoic acid (C22:5 n-6), each present substantially in the free acid form.

In various embodiments, AA is present in an amount of no more than about 5% (a/a) of the fatty acids in the composition. In certain embodiments, AA comprises no more than about 4.5% (a/a) of the fatty acids in the composition. In particular embodiments, AA is present in an amount of no more than about 4% (a/a) of the fatty acids in the composition.

In certain embodiments, AA is present in an amount of no more than about 5% (m/m) of the fatty acids in the composition. In certain embodiments, AA comprises no more than about 4.5% (m/m) of the fatty acids in the composition. In particular embodiments, AA is present in an amount of no more than about 4% (m/m) of the fatty acids in the composition.

In certain embodiments, total omega-6 polyunsaturated fatty acids—defined as the sum of linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3 n-6), eicosadienoic acid (C20:2 n-6), dihomo-gamma-linolenic acid (C20:3 n-6), arachidonic acid (C20:4 n-6) and docosapentaenoic acid (C22:5 n-6)—comprise no more than about 10% (a/a) of the fatty acids in the composition. In certain embodiments, total omega-6 polyunsaturated fatty acids—defined as the sum of linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3 n-6), eicosadienoic acid (C20:2 n-6), dihomo-gamma-linolenic acid (C20:3 n-6), arachidonic acid (C20:4 n-6) and docosapentaenoic acid (C22:5 n-6)—comprise no more than about 10% (m/m) of the fatty acids in the composition.

In specific embodiments, the composition is given by Table 11, with each species of PUFA identified therein falling within the range of about −3SD to about +3 SD of the respectively recited average. In certain embodiments, each species of PUFA identified therein falls within the range of about −2SD to about +2 SD of the respectively recited average. In certain embodiments, each species falls within the range of about −1SD to about +1SD of the respectively recited average.

In selected embodiments, the composition is given by Table 13, with each species of PUFA identified therein falling within the range of about −3SD to about +3 SD of the respectively recited average. In certain embodiments, each species falls within the range of about −2SD to about +2 SD of the respectively recited average. In certain embodiments, each PUFA species falls within the range of about −1SD to about +1SD of the respectively recited average.

In certain embodiments, polyunsaturated fatty acids other than omega-3 and omega-6 polyunsaturated fatty acids are present in an amount of no more than about 5% (a/a). In various embodiments, polyunsaturated fatty acids other than omega-3 and omega-6 polyunsaturated fatty acids are present in an amount of no more than about 5% (m/m).

In a variety of embodiments, at least 90% of each of the plurality of species of omega-3 PUFA in the composition is in the free acid form. In certain embodiments, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, even at least 99% of each species of omega-3 PUFA in the composition is present in the free acid form. In exemplary embodiments, at least 90% of the total omega-3 polyunsaturated fatty acid content in the composition is present in the free acid form. In certain embodiments, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, even at least 99% of the total omega-3 polyunsaturated fatty acid content in the composition is present in the free acid form.

In various embodiments, at least 90% of each of the plurality of species of omega-6 PUFA in the composition is in the free acid form. In certain embodiments, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, even at least 99% of each species of omega-6 PUFA in the composition is present in the free acid form. In exemplary embodiments, at least 90% of the total omega-6 polyunsaturated fatty acid content in the composition is present in the free acid form.

In various embodiments, at least 90% of the total polyunsaturated fatty acid in the composition is present in the free acid form. In certain embodiments, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, even at least 99% of the total polyunsaturated fatty acid in the composition is present in the free acid form.

The composition comprises, in typical embodiments, no more than about 3.0% (a/a) saturated fatty acids and no more than about 5.0% (a/a) mono-unsaturated fatty acids. In various embodiments, the composition comprises no more than about 3.0% (m/m) saturated fatty acids and no more than about 5.0% (m/m) mono-unsaturated fatty acids.

In typical embodiments, the composition usefully further comprises an antioxidant. In certain embodiments, the antioxidant is butylated hydroxyanisole (BHA). In some embodiments, the antioxidant is alpha-tocopherol. In some embodiments, alpha-tocopherol is present in an amount of about 0.20-about 0.40% (m/m). In various embodiments, alpha-tocopherol is present in an amount of about 0.25-about 0.35% (m/m). In particular embodiments, alpha-tocopherol is present in an amount of about 0.27-about 0.33% (m/m).

In typical embodiments, the composition comprises no more than about 0.1 ppm ethyl carbamate. In some embodiments, the composition comprises no more than 0.1 ppm ethyl carbamate. In various embodiments, the composition comprises less than 0.1 ppm ethyl carbamate.

5.3. Unit Dosage Forms

In another aspect, the pharmaceutical or neutraceutical composition of DPA-enriched omega-3 PUFAs in free acid form described in Section 5.2 above is usefully packaged in unit dosage forms for oral administration.

In particular embodiments, the dosage form is a capsule. In certain embodiments, the dosage form is a gelatin capsule. In particular embodiments, the gelatin capsule is a hard gelatin capsule. In other embodiments, the dosage form is a soft gelatin capsule.

In various embodiments, the capsule comprises Type A gelatin. In some embodiments, the capsule comprises both Type A and Type B gelatin. Sources of collagen for the production of either type A or type B gelatin include, but are not limited to, cows, pigs and fish.

In various embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for at least 3 months at 40° C. In certain embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for 6 months at 40° C. In certain embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for 12 months at 40° C.

In various embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for at least 3 months at 30° C. In certain embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for 6 months at 30° C. In some embodiments, the capsule is a soft gelatin capsule comprising sufficient porcine Type A gelatin such that the capsule disintegrates within a time period of not more than 30 minutes in purified water at 37° C. after storage for 12 months at 30° C.

In certain embodiments, the capsule is a soft gelatin capsule comprising a mixture of porcine type A gelatin and a type B gelatin. In various such embodiments, at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 40% even at least about 50% (w/w) of the gelatin is porcine type A gelatin. In selected embodiments, at least about 55%, 60%, 65%, 70%, 75% (w/w) of the gelatin is porcine type A gelatin. In particular embodiments, at least 80%, 85%, 90%, even 95% (w/w) of the gelatin is porcine type A gelatin.

In various embodiments, the capsule is a soft gelatin capsule in which the gelatin consists essentially of porcine type A gelatin.

In some embodiments, the capsule is a reduced cross-linked gelatin capsule, such as those described in U.S. Pat. No. 7,485,323, incorporated herein by reference in its entirety.

In certain embodiments, the capsule comprises succinylated gelatin.

In a variety of embodiments, capsules are made from substances that are not animal by-products, such as agar-agar, carrageenan, pectin, konjak, guar gum, food starch, modified corn starch, potato starch, and tapioca. Non-animal sources of materials that can be used to make capsules useful in the oral unit dosage forms described herein are described in U.S. Patent Publication No. 2011/0117180, incorporated herein by reference. In some embodiments, Vegicaps® Capsules (Catalent) are used.

In certain capsular oral unit dosage form embodiments, the capsule is uncoated.

In other capsular oral unit dosage form embodiments, the capsule is coated.

In certain coated capsule embodiments, the fatty acid composition is released in a time-dependent manner. In various embodiments, there is no substantial release of the PUFA composition for at least 30 minutes after ingestion. In certain embodiments, there is no substantial release of the PUFA composition for at least 30 minutes when release is tested in vitro. In certain embodiments, no more than about 20% of the PUFA composition is released within the first 30 minutes when tested in vitro. In selected embodiments, no more than about 25%, 30%, even no more than about 35% of the PUFA composition is released within the first 30 minutes, when tested in vitro. In particular embodiments, in vitro release properties are assessed according to the procedures described in provisional patent application No. 61/749,124, filed Jan. 4, 2013, titled “Method of release testing for omega-3 polyunsaturated fatty acids,” by Bharat Mehta, the disclosure of which is incorporated herein by reference in its entirety.

In particular embodiments, substantial quantities of the PUFA composition are released by about 60 minutes after ingestion. In certain embodiments, substantial quantities of the PUFA composition are released by about 60 minutes when tested in vitro. In selected embodiments, at least about 40% of the PUFA composition is released by about 60 minutes, when tested in vitro. In various embodiments, at least about 45%, 50%, 55%, 60%, even at least about 65% of the PUFA composition is released by about 60 minutes, when tested in vitro. In particular embodiments, in vitro release properties are assessed according to the procedures described in provisional patent application No. 61/749,123, filed Jan. 4, 2013, titled “Method of release testing for omega-3 polyunsaturated fatty acids,” by Mehta, the disclosure of which is incorporated herein by reference in its entirety.

In certain embodiments, capsules are coated as described in U.S. Pat. Nos. 5,792,795 and 5,948,818, the disclosures of which are incorporated herein by reference. In various coated embodiments, the coating is a poly(ethylacrylate-methylacrylate) copolymer. In some embodiments, the coating is Eudragit NE 30-D (Evonik Industries AG), which has an average molecular weight of about 800,000.

In other coated capsule embodiments, the capsule is coated with an enteric coating that protects the capsule from dissolution or disintegration in the stomach but dissolves at pH values encountered in the small intestine.

In various embodiments, the oral unit dosage form contains from about 100 mg to about 2000 mg of the PUFA composition. In some embodiments, the oral dosage form contains about 250 mg of the PUFA composition. In some embodiments, the oral dosage form contains about 500 mg of the PUFA composition. In certain embodiments, the oral dosage form contains about 750 mg of the PUFA composition. In some embodiments, the oral dosage form contains about 1000 mg of the PUFA composition. In other embodiments, the oral dosage form contains about 1500 mg of the PUFA composition. In certain embodiments, the unit dosage form contains nonintegral weight amounts of PUFA composition between 100 mg and 2000 mg.

5.4. Dosage Kits

In another aspect, a plurality of unit dosage forms as above-described may usefully be packaged together in a dosage kit to increase ease of use and patient compliance.

In certain embodiments, the dosage kit is a bottle. In other embodiments, the plurality of dosage forms is packaged in blister packs, a plurality of which blister packs may optionally be packaged together in a box or other enclosure. Typically, whether in a bottle or one or more blister packs, the plurality of unit dosage forms is sufficient for 30 days, 60 days, or 90 days of dosing. Thus, in selected embodiments, the unit dosage form is a capsule containing approximately one gram of pharmaceutical composition as described above, and the dosage kit comprises 30, 60, 90, 120, 150, 180, 240, 270, or 300 such capsules.

In various embodiments, the plurality of unit dosage forms is packaged under an inert gas, such as nitrogen or a noble gas, or is packaged under vacuum.

5.5. Methods of Treatment

In another aspect, methods of treatment are provided.

5.5.1. Treatment of Severe Hypertriglyceridemia (>500 mg/dL)

In a first series of treatment embodiments, methods of treating severe hypertriglyceridemia are provided.

The methods comprise orally administering the pharmaceutical composition described in Section 5.2 above to a patient having pre-treatment serum or plasma triglyceride levels ≥500 mg/dL, in an amount and for a duration sufficient to reduce serum or plasma triglyceride levels below pre-treatment levels. In typical embodiments, each dose of the pharmaceutical composition is administered as one or as a plurality of the unit dosage forms described in Section 5.3, above.

In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least about 5%, 6%, 7%, 8%, or at least about 9% below pre-treatment levels. In certain embodiments, the composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18% or 19% below pre-treatment levels. In particular embodiments, the composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least about 20% below pre-treatment levels. In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce serum or plasma triglycerides by at least about 25%, 30%, 35%, 40%, 45%, even at least about 50% below pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least about 50 mg/dL, 60 mg/dL, 70 mg/dL, 80 mg/dL, 90 mg/dL, even at least about 100 mg/dL. In certain embodiments, the composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least about 110 mg/dL, 120 mg/dL, 130 mg/dL, 140 mg/dL, even at least about 150 mg/dL. In specific embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce serum or plasma triglyceride levels by at least about 160 mg/dL, 170 mg/dL, 180 mg/dL, even at least about 190 mg/dL or 200 mg/dL.

In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to decrease non-HDL-c levels by at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, even at least about 10% below pre-treatment levels.

In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase HDL-c levels by at least about 1% above pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to increase HDL-c by at least about 2%, 3%, 4%, even at least about 5%, 6%, 7%, 8%, 9%, or 10% above pre-treatment levels.

In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce the total cholesterol:HDL-c (“TC/HDL”) ratio by at least about 1% below pre-treatment levels. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to reduce the TC/HDL ratio by at least about 2%, 3%, 4%, 5%, 6%, 7%, 8%, even at least about 9% or at least about 10% below pre-treatment levels.

In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to decrease VLDL-c levels by at least about 5%, 6%, 7%, 8%, 9%, or at least about 10% below pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to decrease VLDL-c levels by at least about 11%, 12%, 13%, 14%, 15%, 16%, 17%, even at least about 18%, 19%, or 20% below pre-treatment levels. In particular embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to decrease VLDL-c levels by at least about 21%, 22%, 23%, 24%, even at least about 25% below pre-treatment levels.

In a variety of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to decrease ApoCIII levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to decrease ApoCIII levels by at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, even at least about 8%, 9% or 10% below pre-treatment levels.

In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma EPA levels by at least 100% above pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma EPA levels by at least about 200%, 250%, 300%, even at least about 350%, 400%, 450% or at least about 500% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered for a time and in an amount effective to increase plasma EPA levels by at least about 550%, 600%, 650%, even at least about 700% above pre-treatment levels.

In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 50% above pre-treatment levels. In particular embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 55%, 60%, 65%, 70%, even at least about 75%, 80%, 85%, or 90% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 50% above pre-treatment levels. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 55%, 60%, 65%, 70%, 75%, even at least about 80%, 85%, 90%, 95%, or 100% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 110%, 120%, even at least about 125% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic acid (AA) concentration in plasma by at least about 5% below pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic (AA) concentration in plasma by at least about 6%, 7%, 8%, 9%, 10%, even at least about 11%, 12%, 13%, 14%, even at least about 15%, 16%, 17%, 18%, 19%, 20%, or 21%, 22%, 23%, 24% even at least about 25% below pre-treatment levels.

In certain embodiments, the pharmaceutical composition is administered in an amount, and for a duration, effect to reduce plasma arachidonic acid concentration by at least about 25 μg/mL. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to reduce plasma AA levels by at least about 50 μg/mL, 55 μg/mL, 60 μg/mL, 65 μg/mL, even at least about 70 μg/mL, 75 μg/mL, 80 μg/mL, 85 μg/mL, 90 μg/mL, even at least about 95 μg/mL or 100 μg/mL.

In certain embodiments, the effective amount is at least about 2 g per day. In various embodiments, the effective amount is at least about 3 g per day. In particular embodiments, the effective amount is at least about 4 g per day. In typical embodiments, the effective amount is about 2 g per day. In certain embodiments, the effective amount is about 4 g per day.

In typical embodiments, the pharmaceutical composition is administered for at least 30 days. In certain embodiments, the pharmaceutical composition is administered for at least 60 days. In particular embodiments, the pharmaceutical composition is administered for at least 90 days, 120 days, 180 days, 240 days, or at least 360 days. In certain embodiments, the pharmaceutical composition is administered indefinitely.

In some embodiments, the pharmaceutical composition is administered daily. In other embodiments, the pharmaceutical composition is administered every other day.

In particular embodiments, the daily dosage of pharmaceutical composition is administered in a single daily dose. In other embodiments, the pharmaceutical composition is administered in divided doses, with the daily dose divided into two administrations, three administrations, or even four administrations, over the course of the day.

In certain embodiments, the pharmaceutical composition is administered with food. In certain embodiments, the pharmaceutical composition is administered with a low fat meal. In other embodiments, the pharmaceutical composition is administered without food. In certain embodiments, the pharmaceutical composition is administered in the fasting state.

The methods, in certain embodiments, further comprising administering a statin. In particular embodiments, the statin is selected from the group consisting of: pravastatin, lovastatin, simvastatin, atorvastatin, fluvastatin, rosuvastatin, tenivastatin, and pitavastatin.

5.5.2. Treatment of Hypertriglyceridemia (200-500 mg/dL)

In another series of treatment embodiments, methods of treating patients who have pre-treatment serum or plasma triglyceride levels of about 200 mg/dL to about 500 mg/dL are provided. In certain embodiments, the patients are already on statin therapy; in these patients, the pre-treatment serum or plasma triglyceride levels are those measured during statin treatment, prior to administration of the pharmaceutical compositions described in Section 5.2 above.

The method comprises orally administering an effective amount of a statin, and further administering the pharmaceutical composition described in Section 5.2 herein, orally, in an amount and for a duration sufficient to lower serum or plasma triglyceride levels below levels measured prior to treatment with the pharmaceutical composition described herein. The pharmaceutical composition described in Section 5.2 and the statin need not be administered at the same time, with the same dosage schedule, or even on the same days. It is sufficient that the two be administered in sufficient temporal proximity that the patient receives therapeutic benefit concurrently from both.

In certain embodiments, the pharmaceutical composition described in Section 5.2 is administered in an amount and for a duration sufficient to reduce serum or plasma triglyceride levels by at least about 5% below pre-treatment levels. In various embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to reduce serum or plasma triglyceride levels by at least about 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, even at least about 16%, 17%, 18%, 19%, or at least about 20% below pre-treatment levels.

In some embodiments, the pharmaceutical composition described in Section 5.2 herein is administered in an amount and for a duration sufficient to reduce non-HDL-cholesterol by at least about 1%, at least about 2%, at least about 3%, 4%, 5%, even at least about 7%, 8%, 9%, or at least about 10% below pre-treatment levels.

In a series of embodiments, the pharmaceutical composition described in Section 5.2 herein is administered in an amount and for a duration sufficient to raise HDL-c levels by at last about 1%, 2%, 3% or more above pre-treatment levels.

In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma EPA levels by at least 100% above pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma EPA levels by at least about 200%, 250%, 300%, even at least about 350%, 400%, 450% or at least about 500% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered for a time and in an amount effective to increase plasma EPA levels by at least about 550%, 600%, 650%, even at least about 700% above pre-treatment levels.

In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 50% above pre-treatment levels. In particular embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 55%, 60%, 65%, 70%, even at least about 75%, 80%, 85%, or 90% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 50% above pre-treatment levels. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 55%, 60%, 65%, 70%, 75%, even at least about 80%, 85%, 90%, 95%, or 100% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 110%, 120%, even at least about 125% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic acid (AA) concentration in plasma by at least about 5% below pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic (AA) concentration in plasma by at least about 6%, 7%, 8%, 9%, 10%, even at least about 11%, 12%, 13%, 14%, even at least about 15%, 16%, 17%, 18%, 19%, 20%, or 21%, 22%, 23%, 24% even at least about 25% below pre-treatment levels.

In certain embodiments, the pharmaceutical composition is administered in an amount, and for a duration, effect to reduce plasma arachidonic acid concentration by at least about 25 μg/mL. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to reduce plasma AA levels by at least about 50 μg/mL, 55 μg/mL, 60 μg/mL, 65 μg/mL, even at least about 70 μg/mL, 75 μg/mL, 80 μg/mL, 85 μg/mL, 90 μg/mL, even at least about 95 μg/mL or 100 μg/mL.

In various embodiments, the pharmaceutical composition described in Section 5.2 herein is administered in unit dosage forms as described in Section 5.3 above.

In various embodiments, the pharmaceutical composition is administered in an amount of at least about 1 g per day. In some embodiments, the pharmaceutical composition is administered in an amount of at least about 2 g/day. In certain embodiments, the pharmaceutical composition is administered in an amount of at least about 3 g/day. In particular embodiments, the pharmaceutical composition is administered in an amount of at least about 4 g/day. In typical embodiments, the pharmaceutical composition is administered in an amount of about 2 g/day. In certain embodiments, the pharmaceutical composition is administered in an amount of about 3 g/day or about 4 g per day.

5.5.3. Treatment to Increase Plasma EPA:AA Ratios

Methods are also provided for increasing the EPA:AA ratio, without regard to the patient's pre-treatment plasma triglyceride levels. The methods comprise administering the pharmaceutical composition described in Section 5.2 herein to a patient having an EPA:AA ratio below about 0.25, in an amount and for duration sufficient to increase the patient's EPA:AA ratio to at least about 0.25. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to increase the patient's EPA:AA ratio to at least about 0.3, at least about 0.35, at least about 0.40, at least about 0.45, at least about 0.50, even to a level of at least about 0.55, 0.60, 0.61, 0.62, 0.63, 0.64, or 0.65.

In certain embodiments, the method comprises administering the pharmaceutical composition in an amount and for a duration effective to increase plasma EPA levels by at least 100% above pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma EPA levels by at least about 200%, 250%, 300%, even at least about 350%, 400%, 450% or at least about 500% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered for a time and in an amount effective to increase plasma EPA levels by at least about 550%, 600%, 650%, even at least about 700% above pre-treatment levels.

In various embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 50% above pre-treatment levels. In particular embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DHA levels by at least about 55%, 60%, 65%, 70%, even at least about 75%, 80%, 85%, or 90% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 50% above pre-treatment levels. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 55%, 60%, 65%, 70%, 75%, even at least about 80%, 85%, 90%, 95%, or 100% above pre-treatment levels. In selected embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to increase plasma DPA levels by at least about 110%, 120%, even at least about 125% above pre-treatment levels.

In a series of embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic acid (AA) concentration in plasma by at least about 5% below pre-treatment levels. In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration effective to reduce arachidonic (AA) concentration in plasma by at least about 6%, 7%, 8%, 9%, 10%, even at least about 11%, 12%, 13%, 14%, even at least about 15%, 16%, 17%, 18%, 19%, 20%, or 21%, 22%, 23%, 24% even at least about 25% below pre-treatment levels.

In certain embodiments, the pharmaceutical composition is administered in an amount, and for a duration, effect to reduce plasma arachidonic acid concentration by at least about 25 μg/mL. In some embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to reduce plasma AA levels by at least about 50 μg/mL, 55 μg/mL, 60 μg/mL, 65 μg/mL, even at least about 70 μg/mL, 75 μg/mL, 80 μg/mL, 85 μg/mL, 90 μg/mL, even at least about 95 μg/mL or 100 μg/mL.

In various embodiments, the pharmaceutical composition described in Section 5.2 herein is administered in unit dosage forms as described in Section 5.3 above.

In various embodiments, the pharmaceutical composition is administered in an amount of at least about 1 g per day. In some embodiments, the pharmaceutical composition is administered in an amount of at least about 2 g/day. In certain embodiments, the pharmaceutical composition is administered in an amount of at least about 3 g/day. In particular embodiments, the pharmaceutical composition is administered in an amount of at least about 4 g/day. In typical embodiments, the pharmaceutical composition is administered in an amount of about 2 g/day. In certain embodiments, the pharmaceutical composition is administered in an amount of about 3 g/day or about 4 g per day.

5.5.4. Treatment to Lower Serum or Plasma ApoCIII Levels

Methods are also provided for decreasing a patient's serum or plasma ApoCIII levels, without regard to the patient's pre-treatment plasma triglyceride levels. The methods comprise administering the pharmaceutical composition described in Section 5.2 herein to a patient in need of lower ApoCIII levels, in an amount and for duration sufficient to decrease the patient's serum or plasma ApoCIII levels. In typical embodiments, the patient is at risk for cardiovascular heart disease.

In certain embodiments, the pharmaceutical composition is administered in an amount and for a duration sufficient to decrease ApoCIII levels by at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, even at least about 8%, 9% or 10% below pre-treatment levels.

5.5.5. Other Methods of Treatment

In another aspect, the pharmaceutical compositions described herein is used to treat other disorders, including one or more of nonalcoholic steatohepatitis (NASH), hyperlipoproteinemia, including type III hyperlipoproteinemia, and metabolic syndrome.

In certain embodiments, the pharmaceutical composition is used to reduce resistance to platelet aggregation inhibitors, such as Plavix, including use in the methods described in U.S. patent application Ser. No. 13/620,312, the disclosure of which is incorporated herein by reference in its entirety.

5.6. Process

In another aspect, an improved process is presented for refining fish oil into pharmaceutical compositions comprising PUFAs in free acid form, and particularly for refining fish oil into the pharmaceutical compositions described in Section 5.2 herein.

5.6.1. Preparation of Intermediate Feedstock

The intermediate feedstock is prepared by transesterification of the body oil obtained from fish, for example fish from families Engraulidae, Clupeidae and Scombridae, by standard techniques well-known in the art, with process parameters adjusted so as to achieve a composition falling within the tolerances described in section 5.6.2 immediately below.

Suitable standard process steps are described, e.g., in U.S. Pat. Nos. 5,656,667; 5,719,302; 5,945,318; 6,204,401; 6,518,049; 6,528,669; 7,491,522; 7,550,613; 7,678,930; 7,718,698; 7,732,488 and in U.S. Pat. Nos. 5,472,705; 5,750,572; 5,776,978; 5,869,714; 7,541,480; 7,553,870; and 7,619,002, incorporated herein by reference.

In an exemplary process, a crude triglyceride oil is extracted from fish, such as anchovy, sardine, mackerel and menhaden. The crude triglyceride oil is then alkali refined, e.g. using sodium hydroxide, and deodorized, polished, and dried. The PUFAs are then converted to esters, such as methyl esters or ethyl esters, by transesterification. Transesterification can be performed, for example, by ethanolysis in the presence of ethanol and sodium ethoxide to produce ethyl esters. Transesterification is followed by at least one round, typically a plurality of rounds, of distillation.

In another exemplary process, triglyceride oil is alkali refined and deodorized, transesterified with ethanol, such as by ethanolysis in the presence of ethanol and sodium ethoxide, and then subject to one or more rounds of fractional distillation.

FIG. 2 presents a flow chart of an exemplary process for producing the intermediate feedstock. In this process, fish are cooked in water and the resulting mixture of liquids and solids are filtered and the liquid portion centrifuged to remove the aqueous phase. The oily fraction remaining from the preceding step is treated with alkali to neutralize any free fatty acids present, followed by water washing. Thereafter, alkali refined fish oil in the triglyceride form is deodorized and environmental pollutants reduced, e.g. by distillation. The dried deodorized fish oil is converted to the ethyl ester form using reaction with ethanol, catalyzed by the use of sodium ethoxide. After completion of the reaction, the excess ethanol is removed by distillation and the ethyl esters washed with a citric acid solution and then with water. In this exemplary process, the ethyl esters are distilled to achieve the required concentration of EPA ethyl ester (EPA-EE) and DHA ethyl ester (DHA-EE) for use as an intermediate feedstock. In some embodiments, multiple rounds of distillation are performed. The exact conditions used are adjusted depending on the composition of the input ethyl ester composition in order to achieve the required concentration of EPA-EE and DHA-EE for the intermediate feedstock, as detailed in section 5.6.2 immediately below.

Alternatives to these process steps are well known, and may be used as appropriate so long as the resulting intermediate feedstock composition falls within the tolerances defined in section 5.6.2 immediately below.

5.6.2. Intermediate Feedstock Composition

The intermediate feedstock composition comprises a plurality of species of omega-3 PUFAs, each present substantially in the form of an ethyl ester.

The intermediate feedstock composition comprises EPA, DHA, and DPA, each substantially in the form of an ethyl ester.

In various embodiments, the intermediate feedstock composition comprises EPA ethyl ester (EPA-EE), DHA-EE, and DPA-EE, in an amount, calculated as a percentage by area on GC chromatogram of all fatty acid ethyl esters in the composition, falling within the range of −3SD to +3 SD of the averages respectively recited in Table 9. In certain embodiments, each of EPA-EE, DHA-EE, and DPA-EE falls within −2SD to +2 SD of the respectively recited average. In certain embodiments, each of EPA-EE, DHA-EE, and DPA-EE falls with −1SD to +1SD of the respectively recited average. In certain embodiments, the intermediate feedstock composition comprises EPA-EE, DHA-EE, and DPA-EE within the range set by their respective minima and maxima area percentages among the batches described in Table 8.

In certain embodiments, the composition further comprises one or more omega-3 polyunsaturated fatty acids, each substantially in the form of the ethyl ester, selected from the group consisting of: α-linolenic acid (C18:3 n-3), moroctic acid (C18:4 n-3), eicosatrienoic acid (C20:3 n-3), eicosatetraenoic acid (C20:4 n-3), and heneicosapentaenoic acid (C21:5 n-3). In various embodiments, the one or more further species of omega-3-EE, if present, is present in an amount, calculated as a percentage by area on GC chromatogram of all fatty acid ethyl esters in the composition, falling within the range of −3SD to +3 SD of the averages respectively recited in Table 9. In certain embodiments, each species falls within −2SD to +2 SD of the respectively recited average. In certain embodiments, each species falls with −1SD to +1SD of the respectively recited average. In certain embodiments, the one or more further species of omega-3-EE, if present, is present in an amount, calculated as a percentage by area on GC chromatogram of all fatty acid ethyl esters in the composition, falling within the range set by their respective minima and maxima area percentages among the batches described in Table 8.

In certain embodiments, the intermediate feedstock composition also comprises at least one species of omega-6 PUFA. In various embodiments, the composition comprises ethyl esters of one or more omega-6 polyunsaturated fatty acid selected from the group consisting of: linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3 n-6), eicosadienoic acid (C20:3 n-6), dihomo-gamma-linolenic acid (“DGLA”) (C20:3 n-6), arachidonic acid (C20:4 n-6) (“AA”), and docosapentaenoic acid (C22:5 n-6). Each species of omega-6 PUFA is present substantially in ethyl ester form.

In various embodiments, the one or more species of omega-6-EE, if present, is present in an amount, calculated as a percentage by area on GC chromatogram of all fatty acid ethyl esters in the composition, falling within the range of −3SD to +3 SD of the averages respectively recited in Table 9. In certain embodiments, each species falls within −2SD to +2 SD of the respectively recited average. In certain embodiments, each species falls with −1SD to +1SD of the respectively recited average. In certain embodiments, the one or more further species of omega-3-EE, if present, is present in an amount, calculated as a percentage by area on GC chromatogram of all fatty acid ethyl esters in the composition, falling within the range set by their respective minima and maxima area percentages among the batches described in Table 8.

5.6.3. Urea Complexation

Intermediate transesterified feedstock having a composition as above-defined is subjected to urea inclusion complexation. In typical embodiments, the amount of urea used for complexation falls within an algorithmically-determined range.

Thus, in another aspect, an improved process is presented for refining fish oil into pharmaceutical compositions comprising PUFAs in free acid form, particularly for refining fish oil into the pharmaceutical compositions described herein. The improvement comprises subjecting an intermediate feedstock of transesterified fish oil comprising the ethyl esters of various omega-3 and omega-6 PUFA species in defined percentage ranges to a step of urea inclusion complexation, wherein the amount of urea used for complexation is within the range calculated according to (i) formula I(a), or (ii) according to formula I(b), or (iii) according to both formula I(a) and formula I(b) with the urea amount set to a value within the range set by, and inclusive of, the results of formulae I(a) and I(b), such as an average thereof, wherein the formulae are as follows: [Urea]=F _(enrichment-DHA)*((DHA _(target) −DHA-EE _(input))/DHA-EE _(input)))  (Ia) [Urea]=F _(enrichment-EPA)*((EPA _(target) −EPA-EE _(input))/EPA-EE _(input)))  (Ib).

The DHA and EPA target values are selected based on the desired final composition. The enrichment factors, F_(enrichment-DHA) and F_(enrichment-EPA), can be the same or different. In a typical embodiment, F_(enrichment-DHA) and F_(enrichment-EPA) are the same, with a value of about 100/0.34, or about 300.

Using the algorithmically determined amount of urea, complexation is performed according to standard techniques. See, e.g., U.S. Pat. Nos. 4,377,526; 5,106,542; 5,243,046; 5,679,809; 5,945,318; 6,528,669; 6,664,405; 7,541,480; 7,709,668; and 8,003,813, the disclosures of which are incorporated herein by reference.

In an exemplary embodiment, the intermediate feedstock is mixed with a solution of urea in ethanol. The complexation is carried out at 60° C.-80° C., the mixture is then cooled, and the mixture is thereafter filtered or centrifuged to remove urea complexes. Ethanol is removed by distillation and the oil washed several times with water.

5.6.4. Post-Complexation Finishing

Following removal of urea complexes, the uncomplexed PUFA esters are hydrolyzed to free fatty acids by standard techniques. The composition is further purified by distillation, either before or after hydrolysis, and further finished using one or more of the following standard techniques: treatment with active carbon, chromatographic purification, solvent removal, bleaching, e.g. with bleaching earth, and supercritical extraction. Antioxidants, such as BHA or α-tocopherol, are added.

6. EXAMPLES 6.1. Example 1: Urea Complexation is Required for Reliable Production of Omega-3 PUFA Compositions in Free Acid Form that Meet Specification Requirements

Urea inclusion complexation (clathration) is a standard step often used in the refining of fish oils to remove saturated and mono-unsaturated long chain fatty acids, thus enriching for desired long chain omega-3 polyunsaturated fatty acids in the resulting composition. Despite long usage, however (see, e.g., U.S. Pat. No. 4,377,526), and studies designed to characterize the effects of various physiochemical parameters on the process (see, e.g., Hayes et al., “Triangular Phase Diagrams To Predict The Fractionation Of Free Fatty Acid Mixtures Via Urea Complex Formation,” Separation Sci. Technol. 36(1):45-58 (2001) and Hayes, “Purification of Free Fatty Acids via Urea Inclusion Compounds,” in Handbook of Functional Lipids (Taylor & Francis Group) (2005)), the degree to which urea complexation enriches individual species of long chain polyunsaturated fatty acids, including species of both omega-3 PUFAs, and omega-6 PUFAs, remains unpredictable. This residual unpredictability in the urea complexation procedure, and the potential for urea complexation to generate impermissible levels of ethyl carbamate, which would obligate further processing, initially militated in favor of omitting urea complexation from the commercial scale refining process to be used for producing pharmaceutical grade compositions of omega-3 PUFAs in free acid form meeting the specifications set forth in Table 1, below.

TABLE 1 Initial Target Specifications Parameter (all species to be present as free acid) Specification limit EPA 50.0-60.0% (m/m) DHA 15.0-25.0% (m/m) EPA + DHA 70.0-80.0% (m/m) Total omega-3 fatty acids 80.0-90.0% (m/m) Arachidonic Acid nmt 4.5% (a/a) Saturated fatty acids nmt 3.0% (a/a) Mono-unsaturated fatty acids nmt 5.0% (a/a) Omega-6 fatty acids nmt 10.0% (a/a) Other unsaturated fatty acids nmt 5.0% (a/a) Total unidentified above 0.1% nmt 2.0% (a/a) “(m/m)”—percentage, by weight, of all fatty acids in the composition “(a/a)”—percentage by area on gas chromatogram of all fatty acids in the composition “nmt”—“no more than”.

Early efforts to develop a urea-free process, however, demonstrated that such processes could not reliably produce pharmaceutical compositions on a commercial scale that met the required target compositional specification. Table 2, below, presents data on two such lots. Values that fell outside of the desired specification range are underlined.

TABLE 2 Batch 1 Batch 2 Parameter (non-winterized) (winterized) (all species to be present as free acid) Specification limit (m/m) (a/a) (m/m) (a/a) EPA 50.0-60.0% (m/m) 49.0  51.5  49.8  53.0  DHA 15.0-25.0% (m/m) 19.6  20.3  19.6  20.9  EPA + DHA 70.0-80.0% (m/m) 68.3  71.8  69.4  73.9  Total omega-3 fatty acids 80.0-90.0% (m/m) 78.0  81.2  79.3  83.7  Arachidonic Acid nmt 4.5% (a/a) 2.8 2.8 2.9 2.8 Saturated fatty acids nmt 3.0% (a/a) 1.9 2.6 0.6 0.5 Mono-unsaturated fatty acids nmt 5.0% (a/a) 6.6 5.1 6.7 5.1 Omega-6 fatty acids nmt 10.0% (a/a) 4.2 5.3 4.3 5.2 Other unsaturated fatty acids nmt 5.0% (a/a) 2.7 0.3 2.1 0.4 Total unidentified above 0.1% nmt 2.0% (a/a) 5.4 5.5 6.3 5.4

Accordingly, a process using urea complexation was sought, and it was discovered that strict compositional control on the PUFA species present in the intermediate ethyl ester feedstock, coupled with use of urea amounts within ranges set algorithmically, could reliably produce pharmaceutical compositions meeting the specifications set forth in Table 1 without exceeding acceptable ethyl carbamate limits.

The compositional requirements for the intermediate ethyl ester feedstock are presented in Section 5.6.2 and Examples 2 and 4. See Tables 3-6, 8-9.

The optimal amount of urea required to be used was found to be determined by (i) formula I(a), or (ii) according to formula I(b), or (iii) according to both formula I(a) and formula I(b), with the urea amount set to a value within the range set by, and inclusive of, the results of formulae I(a) and I(b), such as the average of the two results, wherein the formulae are as follows: [Urea]=F _(enrichment-DHA)*((DHA _(target) −DHA-EE _(input))/DHA-EE _(input)))  (Ia) [Urea]=F _(enrichment-EPA)*((EPA _(target) −EPA-EE _(input))/EPA-EE _(input)))  (Ib). The enrichment factors, F_(enrichment-DHA) and F_(enrichment-EPA), can be the same or different. A typical value, using the intermediate feedstock batches described in Examples 2 and 4, has been found to be about 100/0.34 (i.e., about 300) for both.

6.2. Example 2: Compositional Analysis of Four Exemplary Production Batches Produced Using Controlled Urea Complexation Confirm that Specification Requirements were Met

Four exemplary production batches of polyunsaturated fatty acids in free acid form were prepared. Strict compositional controls were applied to the ethyl ester intermediate feedstock, using only batches in which specified species of polyunsaturated fatty acids fell within defined range limits. Urea amounts to be used for complexation at production scale were first determined empirically at lab scale, using small test batches of the ethyl ester intermediate feedstock and varying the concentration of urea, thereby varying the oil:urea:ethanol ratio. The optimal concentration suggested by the test scale determinations was confirmed to fall within the range required by the algorithm described in Example 1, and used for production scale manufacture.

The composition of the intermediate transesterified feedstock and the final pharmaceutical composition (“active pharmaceutical ingredient”, or “API”), was determined by gas chromatography. Results are compiled in Tables 3-6, below.

TABLE 3 Intermediate API Feedstock (final free (transesterified fatty acid PUFA species ethyl esters) composition) (common name) (identity) (% a/a) (% a/a) linoleic acid 18:2 n-6 0.54 0.55 gamma-linolenic acid 18:3 n-6 0.00 0.15 α-linolenic acid 18:3 n-3 0.45 0.39 moroctic acid 18:4 n-3 1.52 1.70 eicosadienoic acid 20:2 n-6 0.00 0.10 dihomo-gamma- 20:3 n-6 0.47 0.35 linolenic acid arachidonic acid (AA) 20:4 n-6 2.11 2.43 eicosatrienoic acid 20:3 n-3 0.00 0.15 eicosatetraenoic acid 20:4 n-3 1.78 2.18 eicosapentaenoic acid 20:5 n-3 49.42 57.25 (EPA) heneicosapentaenoic acid 21:5 n-3 2.32 2.79 docosapentaenoic acid 22:5 n-6 0.71 0.83 docosapentaenoic acid 22:5 n-3 5.80 6.23 (DPA) docosahexaenoic acid 22:6 n-3 17.09 19.58 (DHA) Aggregate Metrics Total % 99.41 98.43 PUFAs % 82.77 96.30 Total 78.37 90.26 Omega 3 Total 3.83 4.41 Omega 6 Remaining 0.57 1.63 PUFAs Saturates % 4.34 0.35 Mono- 12.30 1.34 unsaturates % Unknowns % 0.60 0.42

TABLE 4 Intermediate API Feedstock (final free (transesterified fatty acid PUFA species ethyl esters) composition) (common name) (identity) (% a/a) (% a/a) linoleic acid 18:2 n-6 0.54 0.49 gamma-linolenic acid 18:3 n-6 0.00 0.14 α-linolenic acid 18:3 n-3 0.45 0.34 moroctic acid 18:4 n-3 1.52 1.67 eicosadienoic acid 20:2 n-6 0.00 0.13 dihomo-gamma- 20:3 n-6 0.47 0.39 linolenic acid arachidonic acid (AA) 20:4 n-6 2.11 2.45 eicosatrienoic acid 20:3 n-3 0.00 0.25 eicosatetraenoic acid 20:4 n-3 1.78 2.02 eicosapentaenoic acid 20:5 n-3 49.42 57.64 (EPA) heneicosapentaenoic acid 21:5 n-3 2.32 2.75 docosapentaenoic acid 22:5 n-6 0.71 0.79 docosapentaenoic acid 22:5 n-3 5.80 6.22 (DPA) docosahexaenoic acid 22:6 n-3 17.09 19.65 (DHA) Aggregate Metrics Total % 99.41 98.60 PUFAs % 82.77 96.35 Total 78.37 90.54 Omega 3 Total 3.83 4.38 Omega 6 Remaining 0.57 1.43 PUFAs Saturates % 4.34 0.31 Mono- 12.30 1.25 unsaturates % Unknown % 0.60 0.69

TABLE 5 Intermediate API Feedstock (final free (transesterified fatty acid PUFA species ethyl esters) composition) (common name) (identity) (% a/a) (% a/a) linoleic acid 18:2 n-6 0.54 0.59 gamma-linolenic acid 18:3 n-6 0.00 0.12 α-linolenic acid 18:3 n-3 0.38 0.38 moroctic acid 18:4 n-3 1.09 1.16 eicosadienoic acid 20:2 n-6 0.00 0.12 dihomo-gamma- 20:3 n-6 0.57 0.45 linolenic acid arachidonic acid 20:4 n-6 2.42 2.84 eicosatrienoic acid 20:3 n-3 0.00 0.22 eicosatetraenoic acid 20:4 n-3 1.97 2.11 eicosapentaenoic acid 20:5 n-3 49.20 55.81 (EPA) heneicosapentaenoic acid 21:5 n-3 2.30 2.72 docosapentaenoic acid 22:5 n-6 0.64 0.13 docosapentaenoic acid 22:5 n-3 5.06 5.46 (DPA) docosahexaenoic acid 22:6 n-3 17.64 19.45 (DHA) Aggregate Metrics Total % 99.60 98.76 PUFAs % 82.48 93.77 Total 77.64 87.31 Omega 3 Total 4.36 4.24 Omega 6 Remaining 0.48 2.22 PUFAs Saturates % 5.15 0.24 Mono- 11.98 2.97 unsaturates % Unknowns % 0.40 1.79

TABLE 6 Intermediate API Feedstock (final free (transesterified fatty acid PUFA species ethyl esters) composition) (common name) (identity) (% a/a) (% a/a) linoleic acid 18:2 n-6 0.55 0.55 gamma-linolenic acid 18:3 n-6 0.00 0.12 α-linolenic acid 18:3 n-3 0.38 0.37 moroctic acid 18:4 n-3 1.13 1.26 eicosadienoic acid 20:2 n-6 0.36 0.00 dihomo-gamma- 20:3 n-6 0.56 0.42 linolenic acid arachidonic acid (AA) 20:4 n-6 2.43 2.86 eicosatrienoic acid 20:3 n-3 0.00 0.16 eicosatetraenoic acid 20:4 n-3 1.82 2.09 eicosapentaenoic acid 20:5 n-3 48.84 57.08 (EPA) heneicosapentaenoic acid 21:5 n-3 2.28 2.78 docosapentaenoic acid 22:5 n-6 0.63 0.10 docosapentaenoic acid 22:5 n-3 5.02 5.49 (DPA) docosahexaenoic acid 22:6 n-3 17.61 20.00 (DHA) Aggregate Metrics Total % 99.49 98.74 PUFAs % 82.11 94.94 Total 77.09 89.22 Omega 3 Total 4.53 4.05 Omega 6 Remaining 0.49 1.67 PUFAs Saturates % 5.42 0.40 Mono- 11.96 1.57 unsaturates % Unknowns % 0.51 1.84

All four production batches of API met the compositional specifications set forth in Table 1, above.

6.3. Example 3: Controlled Urea Complexation Differentially Enriches Selected Omega-3 and Omega-6 Species

As expected, the urea complexation step substantially decreased the percentage of saturated fatty acids and mono-unsaturated fatty acids in the resulting composition, thereby substantially enriching for polyunsaturated fatty acids. See Tables 3-6, and FIG. 3A. Unexpectedly, however, performing urea complexation using urea amounts falling within the algorithmically-determined range had a differential effect on enrichment of individual species of omega-3 polyunsaturated fatty acids and omega-6 polyunsaturated fatty acids.

Table 7 provides a qualitative assessment of enrichment of various species of polyunsaturated fatty acid, comparing prevalence in the ethyl ester intermediate feedstock to that in the free acid API, averaged across the four production batches described in Tables 3-6. See also FIG. 3B.

TABLE 7 Qualitative effect of Polyunsaturated fatty acid species controlled urea complexation linoleic acid (C18:2 n-6) neutral gamma-linolenic acid (C18:3 n-6) enriched α-linolenic acid (C18:3 n-3) reduced moroctic acid (C18:4 n-3) enriched eicosadienoic acid (C20:2 n-6) neutral dihomo-gamma-linolenic acid (C20:3 n-6) reduced arachidonic acid (C20:4 n-6) (AA) enriched eicosatrienoic acid (C20:3 n-3) enriched eicosatetraenoic acid (C20:4 n-3) enriched eicosapentaenoic acid (C20:5 n-3) (EPA) enriched heneicosapentaenoic acid (C21:5 n-3) enriched docosapentaenoic acid (C22:5 n-6) reduced docosapentaenoic acid (C22:5 n-3) (DPA) enriched docosahexaenoic acid (C22:6 n-3) (DHA) enriched

Although omega-3 polyunsaturated fatty acids, as a class, are substantially enriched, the effect of urea complexation on omega-6 PUFAs, as a class, is not as predictable. On average, the omega-6 species DGLA and docosapentaenoic acid are reduced in prevalence; gamma-linolenic acid and arachidonic acid are increased; and there is little or no effect on linolenic acid and eicosadienoic acid.

We noted, in particular, that the omega-3 docosapentaenoic acid species, DPA (C22:5 n-3), is enriched, whereas the corresponding omega-6 species, with identical chain length and degree of unsaturation, docosapentaenoic acid (C22:5 n-6), is reduced in prevalence. The divergent effect of urea complexation on enrichment of these two isomers—in conjunction with differences in their relative concentrations in the ethyl ester intermediate feed stock—results in a log order difference in their concentrations in the final, free acid, API. Averaging across the four batches of API presented in Tables 3-6, the omega-3 docosapentaenoic acid species, DPA, is present in the final API at 5.85% (a/a), whereas the omega-6 docosapentaenoic acid species is present at an average concentration of 0.46% (a/a).

At an average concentration of 5.85% (a/a), DPA is the third most prevalent species of polyunsaturated fatty acid in the API, exceeded only by EPA and DHA. At this level, the DPA concentration is also 10-fold greater than that reported for an earlier pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form, termed Purepa, in which DPA was reported to be present at a level of 0.5%. See Belluzzi et al., Dig. Dis. Sci. 39(12): 2589-2594 (1994).

6.4. Example 4: Compositional Analysis of Ten (10) Exemplary Production Batches of API Demonstrates Reproducibly Elevated Levels of DPA

Further production batches were prepared according to the methods described in Example 2.

Data from ten (10) batches of API, inclusive of the four batches described in Tables 3-6 in Example 2, produced from eight (8) different batches of intermediate transesterified (ethyl ester) feedstock, are presented in the tables below. The composition of each of the intermediate feedstock batches is shown in Table 8. Table 9 presents the average (“AVG”), standard deviation (“STDEV”, “SD”), and Delta (“A”, the absolute difference between +1 SD and −1 SD, +2 SD and −2 SD, etc.) across the 8 batches of intermediate feedstock for each of the listed (ethyl ester) species. The composition of each of the ten batches of final API is shown in Table 10, below; Table 11 presents the average, standard deviation, and Delta values for each of the listed (free acid) species across the 10 batches of API.

TABLE 8 Intermediate (Ethyl Ester) Feedstock Batches Batch 1 Batch 2 Batch 3 Batch 4 Batch 5 Batch 6 Batch 7 Batch 8 BV No. 319021 319553 319554 320613 320766 320941 320824 320862 ONC No. 22581 24876 24906 27008 27824 27824 28069 28139 Identity Common name area % area % area % area % area % area % area % area % C18:2(n-6) Linoleic acid 0.552 0.516 0.522 0.571 0.689 0.712 0.657 0.611 C18:3(n-6) Gamma-linolenic 0.166 0.146 0.141 0.157 0.253 0.218 0.283 0.159 acid C18:3(n-3) α-Linolenic acid 0.379 0.368 0.351 0.422 0.516 0.498 0.419 0.491 C18:4(n-3) Moroctic acid 1.403 0.991 1.008 1.100 1.432 1.462 1.372 1.505 C20:2(n-6) Eicosadienoic acid 0.156 0.181 0.194 0.167 0.423 0.366 0.274 0.212 C20:3(n-6) Dihomo-gamma- 0.314 0.384 0.421 0.376 0.415 0.473 0.446 0.398 linolenic acid C20:4(n-6) Arachidonic acid 1.977 2.362 2.316 2.805 2.867 2.884 3.306 2.152 C20:3(n-3) Eicosatrienoic acid 0.171 0.200 0.216 0.181 0.270 0.223 0.220 0.245 C20:4(n-3) Eicosatetraenoic 1.855 1.908 1.870 1.653 2.159 2.142 1.896 2.132 acid C20:5(n-3) EPA 46.131 45.698 44.908 45.317 45.131 45.675 45.416 46.185 C21:5(n-3) Heneicosapenta- 2.239 2.105 2.156 2.165 1.763 1.761 2.140 2.407 enoic acid C22:5(n-6) Docosapentaenoic 0.658 0.575 0.556 0.508 0.535 0.524 0.509 0.572 acid C22:5(n-3) DPA 5.341 4.634 4.598 5.178 2.858 2.874 4.324 4.834 C22:6(n-3) DHA 15.875 16.102 15.997 15.700 16.861 17.046 16.128 16.852

TABLE 9 Intermediate (Ethyl Ester) Feedstock 8 batch statistics Identity Common name AVG SD −3SD −2SD −1SD +1SD +2SD +3SD 1SD Δ 2SD Δ 3SD Δ C18:2(n-6) Linoleic acid 0.60 0.08 0.38 0.45 0.53 0.68 0.76 0.83 0.15 0.30 0.45 C18:3(n-6) Gamma-linolenic 0.19 0.05 0.03 0.08 0.14 0.24 0.30 0.35 0.11 0.22 0.32 acid C18:3(n-3) α-Linolenic acid 0.43 0.06 0.24 0.30 0.37 0.49 0.56 0.62 0.13 0.26 0.38 C18:4(n-3) Moroctic acid 1.28 0.21 0.64 0.86 1.07 1.50 1.71 1.93 0.43 0.86 1.28 C20:2(n-6) Eicosadienoic acid 0.25 0.10 −0.05 0.05 0.15 0.35 0.45 0.54 0.20 0.40 0.60 C20:3(n-6) Dihomo-gamma- 0.40 0.05 0.26 0.31 0.36 0.45 0.50 0.55 0.10 0.19 0.29 linolenic acid C20:4(n-6) Arachidonic acid 2.58 0.45 1.23 1.68 2.13 3.03 3.48 3.93 0.90 1.80 2.70 C20:3(n-3) Eicosatrienoic acid 0.22 0.03 0.12 0.15 0.18 0.25 0.28 0.31 0.07 0.13 0.19 C20:4(n-3) Eicosatetraenoic 1.95 0.18 1.42 1.60 1.77 2.13 2.31 2.49 0.36 0.71 1.07 acid C20:5(n-3) EPA 45.56 0.45 44.20 44.65 45.10 46.01 46.46 46.92 0.91 1.81 2.72 C21:5(n-3) Heneicosapentaenoic 2.09 0.22 1.42 1.64 1.87 2.32 2.54 2.76 0.45 0.90 1.34 acid C22:5(n-6) Docosapentaenoic 0.56 0.05 0.41 0.46 0.51 0.60 0.65 0.70 0.10 0.20 0.30 acid C22:5(n-3) DPA 4.33 0.96 1.45 2.41 3.37 5.29 6.25 7.21 1.92 3.84 5.76 C22:6(n-3) DHA 16.32 0.52 14.77 15.29 15.80 16.84 17.36 17.87 1.04 2.07 3.10

TABLE 10 Final (free acid) API Batches Batch Batch 1 Batch 2 Batch 3 Batch 4 Batch 5 Batch 6 Batch 7 Batch 8 Batch 9 10 API Batch # 36355 36395 37225 37289 38151 38154 38157 38300 38303 38306 Intermediate Batch # 1 1 2 3 4 4 5 7 8 6 Identity Common name area % area % area % area % area % area % area % area % area % area % C18:2(n-6) Linoleic acid 0.55 0.49 0.59 0.55 0.60 0.61 0.78 0.62 0.53 0.72 C18:3(n-6) Gamma-linolenic acid 0.15 0.14 0.12 0.12 0.17 0.16 0.16 0.22 0.15 0.15 C18:3(n-3) α-Linolenic acid 0.39 0.34 0.38 0.37 0.45 0.45 0.55 0.41 0.44 0.50 C18:4(n-3) Moroctic acid 1.70 1.67 1.16 1.26 1.37 1.37 1.87 1.65 1.77 1.81 C20:2(n-6) Eicosadienoic acid 0.10 0.13 0.12 0.09 0.10 0.10 0.27 0.12 0.11 0.12 C20:3(n-6) Dihomo-gamma-linolenic 0.35 0.39 0.45 0.42 0.42 0.45 0.52 0.51 0.42 0.51 acid C20:4(n-6) Arachidonic acid 2.43 2.45 2.84 2.86 3.50 3.50 3.64 4.02 2.57 3.60 C20:3(n-3) Eicosatrienoic acid 0.15 0.25 0.22 0.16 0.20 0.17 0.25 0.18 0.17 0.23 C20:4(n-3) Eicosatetraenoic acid 2.18 2.02 2.11 2.09 1.96 1.90 2.64 2.13 2.34 2.54 C20:5(n-3) EPA 57.25 57.64 55.81 57.08 56.25 56.38 56.88 56.30 56.72 57.15 C21:5(n-3) Heneicosapentaenoic acid 2.79 2.75 2.72 2.78 2.68 2.60 2.15 2.57 2.88 2.18 C22:5(n-6) Docosapentaenoic acid 0.20 0.17 0.72 0.71 0.61 0.62 0.66 0.63 0.71 0.66 C22:5(n-3) DPA 6.23 6.22 5.46 5.49 6.12 5.97 3.41 5.15 5.59 3.43 C22:6(n-3) DHA 19.58 19.65 19.45 20.00 19.16 18.79 20.60 20.10 20.97 21.01

TABLE 11 Final (free acid) API 10 batch statistics −3 −2 −1 +1 +2 +3 Identity Common name AVG SD SD SD SD SD SD SD 1SD Δ 2SD Δ 3SD Δ C18:2(n-6) Linoleic acid 0.61 0.09 0.34 0.43 0.52 0.69 0.78 0.87 0.18 0.35 0.53 C18:3(n-6) Gamma-linolenic acid 0.15 0.03 0.07 0.10 0.13 0.18 0.21 0.24 0.06 0.11 0.17 C18:3(n-3) α-Linolenic acid 0.43 0.06 0.23 0.30 0.36 0.49 0.56 0.62 0.13 0.26 0.39 C18:4(n-3) Moroctic acid 1.56 0.25 0.81 1.06 1.31 1.81 2.06 2.31 0.50 1.00 1.50 C20:2(n-6) Eicosadienoic acid 0.13 0.05 −0.03 0.02 0.07 0.18 0.23 0.29 0.11 0.21 0.32 C20:3(n-6) Dihomo-gamma- 0.44 0.06 0.28 0.33 0.39 0.50 0.56 0.61 0.11 0.22 0.33 linolenic acid C20:4(n-6) Arachidonic acid 3.14 0.58 1.41 1.99 2.57 3.72 4.29 4.87 1.15 2.30 3.46 C20:3(n-3) Eicosatrienoic acid 0.20 0.04 0.08 0.12 0.16 0.24 0.28 0.32 0.08 0.16 0.24 C20:4(n-3) Eicosatetraenoic acid 2.19 0.24 1.46 1.71 1.95 2.43 2.68 2.92 0.49 0.97 1.46 C20:5(n-3) Eicosapentaenoic acid 56.74 0.56 55.07 55.63 56.19 57.30 57.86 58.42 1.12 2.23 3.34 (EPA) C21:5(n-3) Heneicosapentaenoic 2.61 0.25 1.85 2.11 2.36 2.86 3.12 3.37 0.51 1.01 1.52 acid C22:5(n-6) Docosapentaenoic acid 0.57 0.21 −0.05 0.16 0.36 0.78 0.98 1.19 0.41 0.83 1.24 C22:5(n-3) Docosapentaenoic acid 5.31 1.06 2.13 3.19 4.25 6.37 7.42 8.48 2.12 4.23 6.35 (DPA) C22:6(n-3) Docosahexaenoic acid 19.93 0.75 17.68 18.43 19.18 20.68 21.43 22.18 1.50 2.99 4.49 (DHA)

As is evident from Table 11, the log order difference in relative concentration in the API of the omega-3 docosapentaenoic acid species, DPA (C22:5 n-3), and the omega-6 docosapentaenoic acid isomer (C22:5 n-6), is maintained—at 5.31% (a/a) for DPA (C22:5 n-3) vs. 0.57% (a/a) for docosapentaenoic acid (C22:5 n-6)—as is the 10-fold increase in concentration of DPA as compared to the earlier omega-3 free acid Purepa formulation reported in Belluzzi et al. (5.31 vs. 0.5%).

6.5. Example 5: Compositional Analysis of 21 Exemplary Production Batches Demonstrates Reproducibly Elevated Levels of DPA

The high absolute and relative concentration of the omega-3 docosapentaenoic acid species, DPA, has now been observed across 21 batches of API produced using urea complexation, as summarized in Tables 12 and 13, below.

TABLE 12 Final (free acid) API 21 batch statistics Min % Max % AVG % Identity Common name (a/a) (a/a) (a/a) C18:2(n-6) Linoleic acid 0.49 1.00 0.74 C18:3(n-6) Gamma-linolenic acid 0.12 0.52 0.24 C18:3(n-3) a-Linolenic acid 0.34 0.83 0.54 C18:4(n-3) Stearidonic (moroctic) acid 1.16 5.83 2.83 C20:2(n-6) Eicosadienoic acid 0.10 0.27 0.15 C20:3(n-6) Dihomo-gamma-linolenic acid 0.24 0.52 0.40 C20:4(n-6) Arachidonic acid (AA) 2.32 4.02 3.17 C20:3(n-3) Eicosatrienoic acid 0.10 0.25 0.16 C20:4(n-3) Eicosatetraenoic acid 1.40 2.82 2.13 C20:5(n-3) Eicosapentaenoic 48.61 57.64 55.40 (timnodonic) acid (EPA) C21:5(n-3) Heneicosapentaenoic acid 1.81 2.88 2.33 C22:5(n-6) Docosapentaenoic acid 0.17 0.73 0.58 C22:5(n-3) Docosapentaenoic acid (DPA) 2.77 6.23 4.44 C22:6(n-3) Cervonic acid (DHA) 15.99 21.78 19.35

TABLE 13 Final (free acid) API 21 batch statistics AVG Identity Common name % (a/a) SD −3SD −2SD −1SD +1SD +2SD +3SD 1SD Δ 2SD Δ 3SD Δ C18:2(n-6) Linoleic acid 0.74 0.16 0.26 0.42 0.58 0.90 1.07 1.23 0.32 0.65 0.97 C18:3(n-6) Gamma-linolenic 0.24 0.11 −0.09 0.02 0.13 0.35 0.46 0.58 0.22 0.44 0.66 acid C18:3(n-3) α-Linolenic acid 0.54 0.15 0.09 0.24 0.39 0.69 0.84 0.99 0.30 0.60 0.90 C18:4(n-3) Stearidonic 2.83 1.49 −1.63 −0.15 1.34 4.31 5.80 7.28 2.97 5.94 8.92 (moroctic) acid C20:2(n-6) Eicosadienoic acid 0.15 0.04 0.02 0.07 0.11 0.20 0.24 0.28 0.09 0.17 0.26 C20:3(n-6) Dihomo-gamma- 0.40 0.07 0.18 0.25 0.32 0.47 0.55 0.62 0.15 0.30 0.45 linolenic acid C20:4(n-6) Arachidonic acid 3.17 0.51 1.65 2.16 2.67 3.68 4.19 4.70 1.01 2.03 3.04 C20:3(n-3) Eicosatrienoic acid 0.16 0.05 0.01 0.06 0.11 0.21 0.26 0.31 0.10 0.20 0.31 C20:4(n-3) Eicosatetraenoic 2.13 0.41 0.92 1.32 1.73 2.54 2.94 3.35 0.81 1.62 2.43 acid C20:5(n-3) Timnodonic acid 55.40 2.13 49.00 51.13 53.27 57.53 59.66 61.80 4.26 8.53 12.79 (EPA) C21:5(n-3) Heneicosapentaenoic 2.33 0.34 1.29 1.64 1.98 2.67 3.02 3.36 0.69 1.38 2.07 acid C22:5(n-6) Docosapentaenoic 0.58 0.16 0.11 0.27 0.43 0.74 0.90 1.06 0.31 0.63 0.94 acid C22:5(n-3) Docosapentaenoic 4.44 1.16 0.98 2.13 3.29 5.60 6.75 7.91 2.31 4.62 6.93 acid (DPA) C22:6(n-3) Cervonic acid 19.35 1.69 14.28 15.97 17.66 21.04 22.73 24.42 3.38 6.76 10.14 (DHA)

6.6. Example 6: DPA's Effects on Hepatic Cell Gene Expression Predict Greater Clinical Efficacy of DPA-Enriched Compositions

DPA is the third most prevalent species of polyunsaturated fatty acid in the pharmaceutical compositions analyzed in the examples above, and is present at a concentration 10-fold that in Purepa, an earlier pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form. Although DPA is an intermediate in the biosynthetic pathway from EPA to DHA (see FIG. 1), surprisingly little is known about the DPA's specific biological effects. See Kaur et al., “Docosapentaenoic acid (22:5n-3): a review of its biological effects,” Prog. Lipid Res. 50:28-34 (2011). To clarify the potential contribution of DPA to clinical efficacy of the pharmaceutical composition, gene expression profiling experiments were conducted.

6.6.1. Methods

Cell Culture and Treatment—

Hep G2 hepatocarcinoma cells were cultured in serum-free Dulbecco's Modified Eagle's Medium (DMEM) (Sigma-Aldrich) with 4.5 g/l glucose, 1-glutamine, NaHCO₃ and pyridoxine HCl supplemented with 1% (vol/vol) nonessential amino acids, 1% Na-pyruvate, 1% penicillin/streptomycin, and 10% (vol/vol) fatty acid-free bovine serum albumin (BSA), all purchased from Gibco BRL.

Cell cultures were transferred weekly by trypsinization and incubated at 37° C. in a humidified incubator containing 5% CO₂. After 5 weeks of cell culture, EPA (eicosapentaenoic acid, lot #0439708-2, Cayman Chemicals), DPA (docosapentaenoic acid, lot 163481-26, Cayman Chemicals), and DHA (docosahexaenoic acid, lot 0437083-5, Cayman Chemicals), diluted immediately before use in serum free DMEM, were added to triplicate wells (250,000 cells/well) at the final effective concentrations set forth in Table 14, below.

Ratios of EPA (at 100 μM), DHA (at 40 μM), and DPA (at 11 μM) were chosen to approximate the ratios of EPA, DHA, and DPA in the pharmaceutical compositions (API) described in Section 5.2 and Example 5 (see Tables 12 and 13). Absolute concentrations were chosen to best approximate—within the constraint imposed by the desired compositional ratios and constraints imposed by the culture conditions—the plasma ranges observed in the 2 g and 4 g treatment arms of the EVOLVE trial (see Example 10). The lower DPA concentration (1 μM) was chosen to approximate the systemic exposure that would be expected from use of the earlier pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form, termed Purepa, in which DPA was reported to be present at a level 1/10 that seen in the current pharmaceutical composition.

The HepG2 cells were incubated with the identified fatty acid (EPA, DHA, DPA, or specified mixtures) for a total of 48 hours prior to cell harvest and RNA extraction.

TABLE 14 Final RNA Sam- concentration quality ple # PUFA species per well Well (260/280) GL 01 EPA 30 μM a 2.0 GL 02 EPA 30 μM b 2.1 GL 03 EPA 30 μM c 2.0 GL 04 EPA 100 μM a 1.98 GL 05 EPA 100 μM b 2.05 GL 06 EPA 100 μM c 2.0 GL 07 DHA 12 μM a 2.0 GL 08 DHA 12 μM b 2.04 GL 09 DHA 12 μM c 2.0 GL 10 DHA 40 uM a 2.0 GL 11 DHA 40 uM b 2.0 GL 12 DHA 40 uM c 2.11 GL 13 DPA 0.3 μM a 2.07 GL 14 DPA 0.3 μM b 2.0 GL 15 DPA 0.3 μM c 2.0 GL 16 DPA 3.0 μM a 2.09 GL 17 DPA 3.0 μM b 2.0 GL 18 DPA 3.0 μM c 1.99 GL 19 DPA 1 μM a 2.2 GL 20 DPA 1 μM b 2.03 GL 21 DPA 1 μM c 2.03 GL 22 DPA 11 μM a 2.0 GL 23 DPA 11 μM b 2.08 GL 24 DPA 11 μM c 2.06 GL 25 EPA:DHA:DPA total 200 μM a 2.05 100:40:1(50:20:0.5) GL 26 EPA:DHA:DPA total 200 μM b 2.0 100:40:1(50:20:0.5) GL 27 EPA:DHA:DPA total 200 μM c 2.0 100:40:1(50:20:0.5) GL 28 EPA:DHA:DPA total 200 μM a 2.0 100:40:11 (50:20:5.5) GL 29 EPA:DHA:DPA total 200 μM b 2.06 100:40:11 (50:20:5.5) GL 30 EPA:DHA:DPA total 200 μM c 2.07 100:40:11 (50:20:5.5) GL 31 EPA:DHA:DPA total 60 μM a 2.07 30:12:0.3 (50:20:0.5) GL 32 EPA:DHA:DPA total 60 μM b 2.13 30:12:0.3 (50:20:0.5) GL 33 EPA:DHA:DPA total 60 μM c 2.05 30:12:0.3 (50:20:0.5) GL 34 EPA:DHA:DPA total 60 μM a 2.0 30:12:3 (50:20:5.5) GL 35 EPA:DHA:DPA total 60 μM b 2.12 30:12:3 (50:20:5.5) GL 36 EPA:DHA:DPA total 60 μM c 2.01 30:12:3 (50:20:5.5) GL 37 BSA (fatty acid free) a 2.03 GL 38 BSA (fatty acid free) b 2.00 GL 39 BSA(fatty acid free) c 2.00

Cell Harvest and RNA Isolation—

Total RNA was isolated using TRIzol, according to manufacturer's instructions (Invitrogen). RNA quality was assessed with a Nanodrop 8000 Spectrophotometer (Thermo Scientific). As set forth in Table 14, above, each of the RNA extractions for each treatment had a 260/280 ratio between 2.0 and 2.2. RNA was then further purified with Qiagen RNeasy columns. From 300 ng of total RNA per prep, the Illumina TotalPrep RNA Amplification kit (Ambion) was used to generate amplified biotinylated cRNA after reverse transcription by the Eberwine procedure. Aliquots of the treated and control RNA samples were sent to a gene expression core lab for analysis. The remainder of the total RNA samples were stored at −70° C.

Expression Assay and Data Analysis—

Specific transcripts within the biotinylated cRNA were measured by fluorescent imaging after direct hybridization to Illumina HT-12 bead arrays, v.4.0. Gene expression data were analyzed using Ingenuity® iReport™ software (Ingenuity Systems, Redwood City, Calif.).

6.6.2. Results 6.6.2.1. Expression Profiling Demonstrates that DPA has Biological Effects Different from EPA and DHA

Although DPA is an intermediate in the biosynthetic pathway from EPA to DHA, and although DPA is known to retroconvert to EPA in vivo, Kaur et al., Prog. Lipid Res. 50:28-34 (2011), we observed markedly different effects on hepatic cell gene expression after incubating with DPA, as compared to effects seen with EPA and with DHA.

For a high-level assessment of similarities and differences in effects on gene expression, we used the Ingenuity® iReport™ software to query the gene expression data for the top 5 responses, ranked by the Ingenuity® iReport™ algorithm, seen after exposure to each of EPA (100 μM), DHA (40 μM), and DPA (11 μM), within various curated categories of genes. Results are cumulated in Table 15, below. An analogous assessment, using a different categorization, is presented in Table 16, which follows. Symbols used are: “

”—attribute is unique to the specified fatty acid species; “

”—attribute is shared with another fatty acid species; and “♦”—attribute was commonly observed with all 3 fatty acid species.

TABLE 15 EPA DHA DPA Diseases and Disorders Cancer ♦ ♦ ♦ Connective Tissue Disorders □ Dermatological Diseases and Conditions □ □ Developmental Disorder □ Hematological Disease □ Immunological Disease □ Infectious Disease ♦ ♦ ♦ Inflammatory Disease □ Renal and Urological Disease □ Reproductive System Disease □ Molecular and Cellular Functions Cellular Compromise □ Cell Death and Survival □ □ Cellular Development ♦ ♦ ♦ Cellular Function and Maintenance □ Cellular Growth and Proliferation ♦ ♦ ♦ Cellular Movement □ Cell-To-Cell Signaling and Interaction □ □ Gene Expression □ RNA Post-Transcriptional Modification □ Physiological System Development and Function Connective Tissue Development and Function □ Hematological System Development and Function □ □ Hematopoiesis □ Immune Cell Trafficking □ Lymphoid Tissue Structure and Development □ Reproductive System Development and Function □ □ Skeletal and Muscular System Development □ and Function Tissue Development □ □ Tissue Morphology □ Tumor Morphology ♦ ♦ ♦ Top Canonical Pathways CD27 Signaling in Lymphocytes IL-17A Signaling in Airway Cells □ □ IL-17A Signaling in Gastric Cells □ □ IL-8 Signaling □ IMLP Signaling of Neutrophils □ Role of IL-17F in Allergic Inflammatory □ Airway Diseases Role of IL-17A in Arthritis ♦ ♦ ♦ Role of IL-17A in Psoriasis □ □ Role of Macrophages, Fibroblasts and □ Endothelial Cells in Rheumatoid Arthritis TREM1 Signaling □

TABLE 16 EPA DHA DPA Tox Lists Cardiac Hypertrophy □ Hepatic Cholestasis ♦ ♦ ♦ Hepatic Stellate Cell Activation □ Increases Transmembrane Potential of □ Mitochondria and Mitochondrial Membrane Liver Necrosis/Cell Death □ Liver Proliferation □ □ Mechanism of Gene Regulation by Peroxisome □ Proliferators via PPARα PPARα/RXRα Activation □ □ Primary Glomerulonephritis Biomarker Panel □ (Human) Renal Necrosis/Cell Death □ □ Clinical Chemistry and Hematology Increased Levels of Albumin □ Increased Levels of Creatinine ♦ ♦ ♦ Increased Levels of Hematocrit □ Increased Levels of Red Blood Cells □ □ Cardiotoxicity Cardiac Arrhythmia □ Cardiac Damage □ Cardiac Dysfunction □ Cardiac Fibrosis □ □ Cardiac Hypertrophy ♦ ♦ ♦ Cardiac Inflammation ♦ ♦ ♦ Cardiac Necrosis/Cell Death □ □ Cardiac Proliferation □ Congenital Heart Anomaly □ Hepatotoxicity Biliary Hyperplasia □ Liver Cholestasis ♦ ♦ ♦ Liver Damage □ Liver Enlargement □ □ Liver Hepatitis □ □ Liver Inflammation ♦ ♦ ♦ Liver Necrosis/Cell Death □ Liver Proliferation □ □ Nephrotoxicity Renal Damage □ □ Renal Hydronephrosis □ Renal Inflammation ♦ ♦ ♦ Renal Necrosis/Cell Death ♦ ♦ ♦ Renal Nephritis ♦ ♦ ♦ Renal Proliferation ♦ ♦ ♦

The data highlight marked differences in the effects of DPA, EPA, and DHA, across multiple categories.

Differences in the effects on gene expression were also observed using a different analysis, in which the specific genes most significantly up-regulated and down-regulated by each of EPA (100 μM), DHA (40 μM) and DPA (11 μM) were identified. The data are respectively compiled in Tables 17 (up-regulated genes) and 18 (down-regulated genes) below. Symbols used are: “→”—expression affected at both DPA concentrations; “

” expression regulated in common with another fatty acid species, identified in parentheses; “♦” gene regulated by all three fatty acid species.

TABLE 17 top genes up-regulated fatty acid species μM Conc. genes DPA 11 ↑ MST1 (includes EG: 15235) □□(DHA) ↑ MGC16121 □ ↑ AMT □ ↑ AHSA2 □♦ ↑ SRSF1 □□(EPA) ↑ HNRNPA2B1 ↑ ALDOC ↑ TOP3B ↑ STK36 ↑ SRSF5 DHA 40 ↑ HIST2AA3/HIST2H2AA4 □(EPA) ↑ AHSA2 ♦ ↑ MT1X ↑ SNORA62 ↑ HIST1H3A (includes others) ↑ MST1 (includes EG: 15235) □(DPA) ↑ HIST2H2AC ↑ LOX □(EPA) ↑ LSMD1 ↑ MRPS34 EPA 100 ↑ HIST2H2BE (includes others) ↑ AHSA2^(♦) ↑ SRSF1 □(DPA) ↑ RGS2 (includes EG: 19735) ↑ HIST2H2AA3/HIST2H2AA4 □(DHA) ↑ MAT2A ↑ ZNF91 ↑ HIST1H3A (includes others) □(DHA) ↑ LOX □(DHA) ↑ GNAI3

TABLE 18 top genes down-regulated fatty acid species μM Conc. Genes DPA 11 ↓ IL8 ♦ ↓ CDKN2AIPNL ♦ ↓ CATSPER2 □♦ ↓ CCBE1 □(DHA) ↓ ALPP □(DHA) ↓ CCL20 ♦ ↓ DDX51 □(DHA) ↓ QRFPR ↓ ZNF14 ↓ RELB □(EPA) DHA 40 ↓ CATSPER2 ♦ ↓ IL8 ♦ ↓ CCL20 ♦ ↓ CDKN2AIPNL ♦ ↓ MAP2K2 ↓ DDX51 □(DPA) ↓ CCBE1 □(DPA) ↓ JOSD1 ↓ ALPP □(DPA) ↓ ZNF652 EPA 100 ↓ IL8 ♦ ↓ CCL20 ♦ ↓ NFKBIA ↓ IER3 ↓ RELB □(DPA) ↓ CATSPER2 ♦ ↓ CDKN2AIPNL ♦ ↓ G0S2 ↓ ZFP38 ↓ HERDSPUD1

Differences in the effects of DPA, EPA, and DHA were also readily be seen by comparing the genes whose expression is uniquely affected by each of the species of omega-3 PUFA.

TABLE 19 Top genes uniquely regulated by DPA (11 μM) Gene EPA DHA DPA  1. ALDOC ↑  2. AMT ↑  3. HNRNPA2B1 ↑  4. MGC16121 ↑  5. PRKCD ←  6. RELA (inhibited) ←  7. SRSF5 ↑  8. STK36 ↑  9. TLR7 (inhibited) ← 10. TOP3B ↑ 11. QRFPR ↓ 12. ZNF14 ↑

TABLE 20 Top genes uniquely regulated by DHA (40 μM) Gene EPA DHA DPA 1. FOXO3 ← 2. LSMD1 ↑ 3. MAP2K2 ↓ 4. MRPS34 ↑ 5. MT1X ↑ 6. NFKB1 ← 7. SNORA62 ↑ 8. TNFSF11 ← 9. ZNF652 ↓

TABLE 21 Top genes uniquely regulated by EPA (100 μM) Gene EPA DHA DPA  1. Beta-estradiol (inhibited) ←  2. GNAI3 ↑  3. G0S2 ↓  4. HERPUD1 ↓  5. HIST2H2BE (includes others) ↑  6. IL2 (inhibited) ←  7. IER3 ↓  8. Lipopolysaccharide (inhibited) ←  9. MAT2A ↑ 10. NFkB (complex) (inhibited) ← 11. NFKBIA ↓ 12. RGS2 (includes EG: 19735) ↑

Differences in the effects of DPA, EPA, and DHA on gene expression can also be seen by comparing the genes whose expression is most significantly affected by at least two of the species of polyunsaturated fatty acid.

TABLE 22 Top genes commonly regulated by DHA and DPA Gene EPA DHA DPA 1. AHSA2 ↑ ↑ ↑ 2. ALPP ↓ ↓ 3. CATSPER2 ↓ ↓ ↓ 4. CCL20 ↓ ↓ ↓ 5. CDKN2AIPNL ↓ ↓ ↓ 6. CCBE ↓ ↓ 7. DDX51 ↓ ↓ 8. IL8 ↓ ↓ ↓ 9. MST1 (includes EG: 15235) ↑ ↑

TABLE 23 Top genes commonly regulated by EPA and DPA Gene EPA DHA DPA 1. AHSA2 ↑ ↑ ↑ 2. CATSPER2 ↓ ↓ ↓ 3. CCL20 ↓ ↓ ↓ 4. CDKN2AIPNL ↓ ↓ ↓ 5. IL8 ↓ ↓ ↓ 6. RELB ↓ ↓ 7. SRSF1 ↑ ↑

These analyses collectively demonstrate that there are marked differences in the effects of EPA, DHA, and DPA across multiple physiological, pharmacological, and biochemical categories. EPA, DHA, and DPA are not identical in effect; the particular species that are present in an omega-3 PUFA composition clearly matter to the physiological effects that the composition will have upon administration.

6.6.2.2. DPA has Significant Activity at Higher, but not Lower, Concentration

Two concentrations of DPA were assessed. As noted above, the higher DPA concentration (at 11 μM), was chosen so that ratios of EPA (at 100 μM), DHA (at 40 μM), and DPA (at 11 μM) would approximate the ratios of EPA, DHA, and DPA in the pharmaceutical compositions (API) described in Section 5.2 and Example 5, with absolute concentrations chosen to best approximate—within the constraint imposed by the desired compositional ratio and constraints imposed by the culture conditions—the plasma ranges observed in the treatment arms of the EVOLVE trial (see Example 10). The lower DPA concentration (1 μM) was chosen to approximate the systemic exposure that would be expected from use of the earlier pharmaceutical composition of omega-3 polyunsaturated fatty acids in free acid form, termed Purepa, in which DPA was reported to be present at a level 1/10 that seen in the current pharmaceutical composition.

Overall, 310 genes were uniquely responsive to the higher, but not the lower, DPA level. The large number of genes that show statistically significant changes in gene expression predicts that DPA will have meaningful biological effects when the higher concentration is reached in vivo. By contrast, the lower DPA concentration is clearly a sub-threshold dose, at least with respect to regulation of these 310 genes, and far less a response would be expected at this lower in vivo plasma concentration.

When effects were assessed on genes that are broadly categorized by the iReport™ software as affecting molecular and cellular function, two subcategories uniquely appear within the top 5, ranked by the Ingenuity® iReport™ algorithm, at the higher, but not lower DPA, concentration—those involved in gene expression, and those affecting RNA post-transcriptional modification. Given the potential for pleiotropic second-order effects caused by changes in the expression of genes that encode proteins that themselves affect gene expression, and in genes encoding proteins that affect post-transcriptional modification, these results suggest that DPA is capable of modulating a large number of metabolic pathways at the higher, but not lower, concentration.

The threshold dose effect can also be seen by focusing on three categories of genes known to be relevant to the clinical effects of omega-3 polyunsaturated fatty acids: genes involved in lipid metabolism, genes involved in cardiovascular physiology, and genes involved in inflammation (assignment of genes to the identified categories performed automatically by the iReport™ software). Results are tabulated in Table 24, below.

TABLE 24 Total gene Total gene Gene responses responses responses Low [DPA] High [DPA] in common Lipid metabolism 2 22 0 Cardiovascular 10 51 6 Inflammatory 18 22 4

As shown in Table 24, only 2 genes involved in lipid metabolism were responsive to the 1 μM concentration of DPA, whereas 22 lipid metabolism genes uniquely responded with statistically significant change in expression upon incubation in the presence of 11 μM DPA. Focusing on lipid metabolism, 1 μM DPA is clearly a sub-threshold dose, whereas 11 μM has significant effects.

A greater number of genes proved responsive to the 1 μM DPA dose in the cardiovascular physiology category, and we observed a five-fold (rather than 10-fold) increase in number of genes affected at 11 μM DPA. An even greater number of genes involved in inflammatory pathways were responsive to 1 μM DPA, with only a minor increase in gene number observed at 11 μM.

The 11 μM in vitro concentration is lower than the ˜90 μM plasma concentration observed in the 4 g/day EVOLVE patients. See Example 10. The results thus predict that a clinically-relevant dose of the DPA-enriched compositions described in Section 5.2 and Example 5 (see Table 12 and 13) will have significant metabolic effects, including effects on lipid metabolism, cardiovascular physiology, and inflammation. Few, if any, of these DPA-specific effects would be expected at the 10-fold lower DPA levels seen in the earlier Purepa preparation.

6.6.2.3. DPA, at Higher Concentration, Affects Expression of Multiple Lipid Metabolism Genes

The 22 lipid metabolism genes that demonstrate statistically significant changes in expression at the 11 μM DPA concentration, but not 1 μM concentration, are identified in Table 25, below.

TABLE 25 Lipid Metabolism Genes Responsive to 11 μM DPA Entrez Gene ID Fold Drug(s) known to affect Symbol Entrez Gene Name for Human Change expression APOA2 apolipoprotein A-II 336 −1.229 CD83 CD83 molecule 9308 −1.629 DGAT1 diacylglycerol O-acyltransferase 1 8694 1.602 omacor DNAJB1 DnaJ (Hsp40) homolog, subfamily B, 3337 −1.489 member 1 FGFR3 fibroblast growth factor receptor 3 2261 1.336 pazopanib GNAI3 guanine nucleotide binding protein (G 2773 1.455 protein), alpha inhibiting activity polypeptide 3 IL8 interleukin 8 3576 −2.535 IL32 interleukin 32 9235 −1.629 IL18 interleukin 18 (interferon-gamma- 3606 −1.347 (includes inducing factor) EG: 16173) IP6K1 inositol hexakisphosphate kinase 1 9807 −1.242 IP6K2 inositol hexakisphosphate kinase 2 51447 1.319 KIT v-kit Hardy-Zuckerman 4 feline 3815 1.239 dasatinib, sunitinib, pazopanib, sarcoma viral oncogene homolog tivozanib, OSI-930, telatinib, tandutinib, imatinib, sorafenib NFKB1 nuclear factor of kappa light 4790 −1.386 polypeptide gene enhancer in B-cells 1 PDPN podoplanin 10630 −1.307 (includes EG: 10630) PGF placental growth factor 5228 −1.284 aflibercept PIP4K2B phosphatidylinositol-5-phosphate 4- 8396 −1.578 kinase, type II, beta PLA2G16 phospholipase A2, group XVI 11145 −1.337 PLIN5 perilipin 5 440503 −1.371 PTGR2 prostaglandin reductase 2 145482 −1.416 PTX3 pentraxin 3, long 5806 −1.536 RGS2 regulator of G-protein signaling 2, 5997 1.289 (includes 24 kDa EG: 19735) STIP1 stress-induced-phosphoprotein 1 10963 −1.469

DPA's effects on expression of several of these genes suggest that DPA, at analogous in vivo concentration, should lead to improvement in various clinically-relevant lipid parameters.

For example, DPA at 11 μM upregulates ACADSB, the short/branched chain acyl-CoA dehydrogenase. The ACADSB gene product is involved in breakdown of triglycerides; upregulation would be expected to result in lower serum triglyceride levels. HMGCR, which is downregulated, encodes HMG-CoA reductase, the rate-limiting enzyme for cholesterol synthesis and the target for statin inhibition. Thus, analogous to statin action, downregulation of expression of the HMGCR gene by DPA should lead to favorable decreases in the total cholesterol:HDL ratio. SQLE, which is also downregulated, encodes squalene epoxidase, which catalyzes the first oxygenation step in sterol biosynthesis and is thought to be one of the rate-limiting enzymes in this pathway. Downregulation of SQLE should also lead to reduced total cholesterol levels.

6.6.2.4. Summary of Expression Profiling Results

Our expression profiling experiments using a hepatic cell line demonstrate that DPA has significant biological activity at a concentration that approximates the plasma levels observed in human patients administered a 4 g daily dose of an exemplary batch of the DPA-enriched pharmaceutical composition.

At this concentration, DPA affects expression of genes in multiple metabolic pathways, including genes in categories known to be relevant to the clinical effects of omega-3 polyunsaturated fatty acids: genes involved in lipid metabolism, genes involved in cardiovascular physiology, and genes involved in inflammation. Significant second-order effects are expected, given the changes we observed in the expression of genes that encode proteins that themselves affect gene expression, and in genes encoding proteins that affect post-transcriptional modification.

Specific effects on expression of several genes involved in lipid metabolism suggest that DPA, at analogous in vivo concentration, should lead to improvement in various clinically-relevant lipid parameters. In particular, we observed DPA-driven upregulation of ACADSB, the short/branched chain acyl-CoA dehydrogenase, expected to result in lower serum triglyceride levels; downregulation of HMGCR, which, like treatment with statins, should lead to favorable decreases in the total cholesterol:HDL ratio; and downregulation in SQLE, which should analogously lead to reduced total cholesterol levels.

These effects are distinguishable from those observed with EPA and DHA.

Our experiments demonstrated statistically significant dose-dependent effects for DPA, with the lower concentration, chosen to mimic the 10-fold lower concentration of DPA in an earlier free acid omega-3 formulation, affecting 10-fold fewer genes than the higher DPA concentration, chosen to mimic the plasma exposure observed in a clinical trial of the DPA-enriched pharmaceutical compositions described here. At least with respect to the 300 genes uniquely regulated by the higher DPA concentration—notably including genes beneficially affecting lipid metabolism—the lower DPA concentration provides subthreshold exposure, and would be expected to provide a subtherapeutic dose in vivo.

6.7. Example 7: ECLIPSE Clinical Trial 6.7.1. Drug Agents

Lovaza®-Prescription Lovaza® capsules were acquired through commercial US sources. According to the FDA-approved product label, each 1-gram capsule of Lovaza® contains at least 900 mg of the ethyl esters of omega-3 fatty acids sourced from fish oils, predominantly a combination of ethyl esters of eicosapentaenoic acid (EPA—approximately 465 mg) and docosahexaenoic acid (DHA—approximately 375 mg). Independent compositional analysis was not performed.

STUDY DRUG (Epanova®)—Type A porcine soft gelatin capsules coated with Eudragit NE 30-D (Evonik Industries AG) were prepared, each containing one gram of a PUFA composition in which the polyunsaturated fatty acids are present in the form of free fatty acids (“API”). The encapsulated API had the composition set forth in Table 26.

TABLE 26 PUFA species API (carbon chain length: (final free fatty number double acid composition) (common name) bonds, omega series) (% a/a) linoleic acid 18:2 n-6 0.55 gamma-linolenic acid 18:3 n-6 0.15 α-linolenic acid 18:3 n-3 0.39 moroctic acid 18:4 n-3 1.70 eicosadienoic acid 20:2 n-6 0.10 dihomo-gamma-linolenic acid 20:3 n-6 0.35 (DGLA) arachidonic acid (AA) 20:4 n-6 2.43 eicosatrienoic acid 20:3 n-3 0.15 eicosatetraenoic acid 20:4 n-3 2.18 eicosapentaenoic acid (EPA) 20:5 n-3 57.25 heneicosapentaenoic acid 21:5 n-3 2.79 docosapentaenoic acid 22:5 n-6 0.83 docosapentaenoic acid (DPA) 22:5 n-3 6.23 docosahexaenoic acid (DHA) 22:6 n-3 19.58 Total % 98.43 PUFAs % 96.30 Total Omega 3 90.26 Total Omega 6 4.41 Remaining PUFAs 1.63 Saturates % 0.35 Mono-unsaturates % 1.35 Unknowns % 0.42

6.7.2. Study Design

An open-label, single dose, randomized, 4-way crossover study of bioavailability was conducted with two different treatments: 4 grams of Epanova® or 4 g of Lovaza®, each administered with a low-fat and high-fat meal to 54 healthy adults. FIG. 4 provides a treatment flow diagram illustrating the design of the study: briefly, after a washout period, subjects were randomized to one of two treatment sequences:

-   (i) Epanova® (low fat)→Lovaza® (low-fat)→Epanova® (high-fat)→Lovaza®     (high fat), or -   (ii) Lovaza® (low-fat)→Epanova® (low-fat)→Lovaza®     (high-fat)→Epanova® (high-fat).

Low-fat period meals (periods 1 and 2): no breakfast (fasting); no-fat lunch (0 g fat; 600 kcal) after the 4-hour blood draw; low-fat dinner (9 g fat; 900 kcal) after the 12-hour blood draw. Low-fat food items were: fat-free yogurt, fruit cup, fat-free Fig Newtons, Lean Cuisine meal. High-fat period meals (periods 3 and 4): high-fat breakfast (20 g fat; 600 kcal) immediately after the 0.5 hour blood draw; high-fat lunch (30 g fat; 900 kcal) after the 4-hour blood draw; and high-fat dinner (30 g fat; 900 kcal) after the 12-hour blood draw. High-fat food items were: breakfast sandwich & powdered mini-donuts; cheese pizza; potato chips; and cheese and ham panini.

Pre-trial screening washout requirements were: 60 days for fish oil, EPA or DHA supplements or fortified foods; 7 days for fish, flaxseed, perilla seed, hemp, spirulina, or black currant oils, statins, bile acid sequestrants, cholesterol absorption inhibitors or fibrates. The crossover washout period was at least 7 days.

The evening before the in-clinic visit, subjects consumed a low-fat dinner 12 hours before time 0 of each treatment period (9 g fat; 900 kcal). Investigational product (Epanova® or LOVAZA®) was administered in the morning after the pre-dose blood draws (time 0). Pharmacokinetic blood sampling for each 2-day treatment period at −1.0, −0.5 and 0 hours (pre-dosing) and post-dosing at 1, 2, 3, 4, 5, 6, 7, 8, 10 and 12 hours (+/−5 minutes) for the 1^(st) day and at 24 hours (+/−15 min) for the 2^(nd) day.

6.7.3. Pharmacokinetic and Statistical Analyses

The following pharmacokinetic parameters for EPA and DHA plasma concentrations were calculated for the baseline-adjusted change in total and individual EPA and DHA concentrations by standard noncompartmental methods: AUC_(0-t), AUC_(0-inf), C_(max), and T_(max).

The primary determinants of bioavailability: ln-transformed area under the plasma concentration versus time curve (AUC_(t)) and maximum measured plasma concentration (C_(max)) over a 24-hour interval for the baseline-adjusted change in total and individual EPA and DHA concentrations.

Plasma concentrations were baseline-adjusted prior to the calculation of pharmacokinetic parameters. Figures are plotted for the baseline-adjusted change in geometric means (ln-transformed).

Analysis of variance (ANOVA) was used to evaluate the ln-transformed pharmacokinetic parameters for differences due to treatments, period, dosing sequence and subjects within sequence.

Ratios of means were calculated using the least square means for ln-transformed AUC_(0-t), AUC_(0-inf), and C_(max).

The ratios of means and their 90% confidence intervals are to lie above the upper limit of 125.00% for AUC_(0-t), AUC_(0-inf) and C_(max) in order to show Epanova® has superior relative bioavailability compared to Lovaza® with regards to diet.

6.7.4. Results

Study population—The study enrolled 54 healthy adults, 41 males (75.9%) and 13 females (24.1%), aged 21 to 77. All of the treatment periods were completed by 51 subjects (94.4%), with 53 subjects (98.1%) completing the low fat portion of the study. The population was predominantly Black or African-American (66.7%) with 31.5% White and 1.8% Asian.

Bioavailability—FIG. 5 compares the bioavailability of total EPA+DHA (baseline-adjusted change) following a single dose (4 g) of Lovaza® during the high-fat and low-fat periods (fasted dose conditions), confirming that the bioavailability of Lovaza® is significantly decreased with the low-fat diet. The baseline-adjusted change in total plasma EPA+DHA levels show that the AUC_(t) for Lovaza® in the low-fat meal period is decreased by 83.3% compared to Lovaza® in the high-fat meal period: 661.6 vs 3959.5 nmol-h/mL, respectively (p<0.0001) (LS mean data in Table 27, below). C_(MAX) of Lovaza® in the low-fat period decreased by 80.6% compared to the high-fat period (p<0.0001) and the T_(MAX) increased 62% in the low-fat period compared to the high-fat period (10.2 vs. 6.3 hrs, respectively; p=0.0001).

TABLE 27 Ratio of Intra 90% Confidence Bioavailability Least Square Mean Means Subject Interval Limits (%) Parameter Low-Fat High-Fat (%) P-value^(a) C.V. %^(b) Lower Upper Baseline-Adjusted Change AUC_(t) 661.63 3959.52 16.7 <0.0001 69.1 3.47 29.95 (nmol · hr/mL) C_(max) (nmol/mL) 86.89 448.63 19.4 <0.0001 70.7 5.50 33.23 T_(max) (hr) 10.19 6.28 162.3 0.0001 54.5 138.32 186.24 Baseline-Adjusted Change (Ln-transformed) Data (Geometric Means) Ln AUC_(t) 652.06 3468.17 18.8 <0.0001 55.3 15.72 22.49 (nmol · hr/mL) Ln C_(max) 60.61 398.07 15.2 <0.0001 69.2 12.35 18.78 (nmol/mL) N = 53 ^(a)p-value is for the Least Square (LS) Mean Difference between Epanova ® and Lovaza ® from the ANOVA model ^(b)covariance %

FIG. 6 compares the bioavailability of total EPA+DHA (baseline-adjusted change) during the high-fat period following a single dose (4 g) of Lovaza® versus a single dose (4 g) of Epanova®, demonstrating that in the high-fat meal periods, in which the bioavailability of Lovaza® was confirmed to be greatest, the bioavailability EPA+DHA was nonetheless significantly greater when administered in free fatty acid form (Epanova®) than as the corresponding ethyl ester omega-3 composition (Lovaza®) (p<0.0007).

FIG. 7 compares the bioavailability of total EPA+DHA (baseline-adjusted change) following a single dose of Epanova® vs. Lovaza® during the low-fat diet period, demonstrating that the baseline-adjusted change in total plasma EPA+DHA levels show a 4.6-fold greater AUC_(t) for Epanova® than Lovaza® during low-fat meal periods: 3077.8 vs. 668.9 nmol-h/mL, respectively (p<0.0001) (LS mean data in Table 28, below). C_(max) of Epanova® is 3.2-fold greater than Lovaza® (p<0.0001) and T_(max) is 20% shorter than LOVAZA® (8 vs 10 hrs, respectively; p=0.0138).

TABLE 28 Ratio of Intra Inter 90% Confidence Least Square Mean Means Subject Subject Interval Limits (%) Bioavailability Parameter Epanova ® Lovaza ® (%) P-value^(a) C.V. %^(b) C.V. %^(b) Lower Upper Baseline-Adjusted Change AUC_(t) (nmol · hr/mL) 3077.83 668.95 460.10 <0.0001 62.9 253 402.77 517.42 C_(max) (nmol/mL) 277.58 86.35 321.46 <0.0001 71.6 48.9 27236 370.56 T_(max)(hr) 8.08 10.21 79.23 0.0138 45.8 24.6 65.60 92.86 Baseline-Adjusted Change (Ln-transformed) Data (Geometric Means) Ln AUC_(t) (nmol · hr/mL) 2651.41 658.09 402.90 <0.0001 63.9 243 329.71 492.33 Ln C_(max) (nmol/mL) 225.79 60.70 371.95 <0.0001 66.3 42.7 304.37 454.53 N = 53 ^(a)p-value is for the Least Square (LS) Mean Difference between Epanova ® and Lovaza ® from the ANOVA model ^(b)covariance %

FIG. 8 compares the bioavailability of EPA (baseline-adjusted change) following a single dose of Epanova® vs. Lovaza® during the low-fat diet period, showing a 13.5-fold greater AUC_(t) for Epanova® than Lovaza® during low-fat meal periods: 578.2 vs. 42.7 μg·h/mL, respectively (p<0.0001) (LS mean data are presented in Table 29, below). C_(MAX) of Epanova® is 5.6-fold greater than Lovaza® (p<0.0001) and T_(MAX) is 12% shorter than Lovaza® (8 vs. 9 hours, respective; p=0.2605).

TABLE 29 Ratio of Intra Inter 90% Confidence Least Square Mean Means Subject Subject Interval Limits (%) Bioavailability Parameter Epanova ® Lovaza ® (%) P-value^(a) C.V. %^(b) C.V. %^(b) Lower Upper Baseline-Adjusted Change AUC_(t) (μg · hr/mL) 578.22 42.67 1355.1 <0.0001 80.8 18.2 1163.8 1546.4 C_(max) (μg/mL) 52.64 9.45 557.0 <0.0001 83.9 49.8 467.32 646.68 T_(max) (hr) 8.06 9.13 88.28 02605 54.7 25.8 71.02 105.54 Baseline-Adjusted Change (Ln-transformed) Data (Geometric Means) Ln AUC_(t) 495.66 48.65 457.09 <0.0001 93.0 23.5 713.46 1283.9 (μg · hr/mL) Ln C_(max) (μg/mL) 39.02 4.66 837.53 <0.0001 102.1 52.3 630.85 1111.9 N = 53 ^(a)p-value is for the Least Square (LS) Mean Difference between Epanova ® and Lovaza ® from the ANOVA model ^(b)Covariance %

FIG. 9 compares the bioavailability of DHA (baseline-adjusted change) following a single dose of Epanova® vs. Lovaza® during the low-fat diet period, showing a 2.2-fold greater AUC_(t) for Epanova® than Lovaza® during low-fat meal periods: 383.1 vs 173.4 μg·hr/mL, respectively (p<0.0001) (LS mean data presented in Table 30, below). C_(max) of Epanova® is 1.9-fold greater than Lovaza® (p<0.0001) and T_(MAX) is 21% shorter than Lovaza® (8 vs. 11 hours, respectively; p=0.0148). The 2.2-fold greater DHA bioavailability in Epanova® vs Lovaza® occurred despite there being 42% less DHA in the Epanova® formulation.

TABLE 30 Ratio of Intra Inter 90% Confidence Least Square Mean Means Subject Subject Interval Limits (%) Bioavailability Parameter Epanova ® Lovaza ® (%) P-value^(a) C.V. %^(b) C.V. %^(b) Lower Upper Baseline-Adjusted Change AUC_(t) (μg · hr/mL) 383.06 173.40 220.91 <0.0001 55.2 32.1 192.10 249.72 C_(max) (μg/mL) 35.50 19.19 185.02 <0.0001 66.0 48.3 154.43 215.61 T_(max) (hr) 8.45 10.72 78.84 0.0148 47.3 24.0 64.82 92.87 Baseline-Adjusted Change (Ln-transformed) Data (Geometric Means) Ln AUC_(t) 337.09 162.19 207.84 <0.0001 61.3 21.4 171.98 251.17 (μg · hr/mL) Ln C_(max) (μg/mL) 30.17 15.00 201.14 <0.0001 52.5 42.2 170.73 236.96 N = 53 ^(a)p-value is for the Least Square (LS) Mean Difference between Epanova ® and Lovaza ® from the ANOVA model ^(b)covariance %

FIGS. 10A and 10B present individual subject AUC_(0-t) responses during the low-fat and high diets expressed as the ratio (%) of low-fat AUC_(0-t) to high-fat AUC_(0-t). Negative ratios were not plotted. The data show that during the low-fat diet period, 30 of 54 (56%) subjects on Epanova® (free fatty acids) versus 3 of 52 (6%) on Lovaza® (ethyl esters) maintained an AUC_(t) that was ≥50% of the respective high-fat diet period AUC_(t).

A total of 51 adverse events were reported by 29 subjects. The most common adverse events were headaches (10 subjects) and loose stools or diarrhea (9 subjects). All adverse events were mild in severity, and none were serious. There were no clinically significant changes in laboratory, vital sign or physical assessments.

6.7.5. Conclusions

The baseline-adjusted change in total EPA+DHA and individual EPA and DHA absorption profiles (AUC) with Epanova® (omega-3 PUFAs in free acid form) were significantly greater than with Lovaza® (omega-3-PUFA ethyl esters) during the high-fat diet period and dramatically better during the low-fat diet period. Furthermore, there was a very profound impact of fat content of the meals on the bioavailability of Lovaza®, whereas the bioavailability of Epanova® was much more predictable due to only a modest food effect. The superior fat-independent bioavailability of Epanova® over Lovaza® is clinically important as subjects with severely elevated triglycerides require a very low-fat diet. These findings demonstrate a significant therapeutic advantage of free fatty acid Omega-3 composition for treatment of severe hypertriglyceridemia in view of the NCEP ATP III recommendation to have these subjects adhere to a low-fat diet during adjunct therapy.

6.8. Example 8: 14 Day Comparative Bioavailability Trial

To determine whether the effects observed after a single dose were maintained after repeat dosing, a longer term study was performed. FIG. 11 is a treatment flow diagram illustrating the design of the 14 day comparative bioavailability trial, in which study drug (Lovaza® or Epanova®) was consumed with a low fat breakfast. In contrast, doses were given fasting in the low fat arm of the original ECLIPSE trial described in Example 7.

Changes from baseline to steady state in EPA and DHA levels in the Lovaza® arm of the 14 day comparative bioavailability were consistent with prior studies, as shown in Table 31, which presents the mean percentage change in EPA and DHA in the identified prior studies.

TABLE 31 Prior third party studies No. No. Δ Δ Drug Study Subjects Weeks EPA (%) DHA (%) omega-3 CK85-013 17 8 276 34 ethyl ester CK85-014 54 12 300 50 CK85-017 29 12 300 50 CK85-019 26 12 200 29 CK85-022 30 12 233 23 CK85-023 28 12 139 11 CK85-95014 30 24 260 54 CK85-95009 22 16 173 −10* CK85-94010 20 6 202  77** CK85-95011 49 12  361** 59 CK85-95012 6 6  156* 40 EPA range (% Δ): (156* - - - 209 - - - 361**) DHA range (% Δ): (−10* - - - 34 - - - 77**)

FIG. 12A plots the mean un-adjusted total EPA+DHA concentrations versus time (linear scale), both for treatment with Lovaza® and treatment with Epanova®. FIG. 12B is a histogram showing the difference in unadjusted EPA+DHA (nmol/mL) for the time points bracketed in FIG. 12A. FIGS. 12A and 12B demonstrate that after 14-days of dosing, accumulation of EPA+DHA from Epanova® was 2.6 fold higher than Lovaza® in subjects maintained on a low-fat diet.

FIG. 13 plots mean baseline-adjusted plasma total EPA+DHA concentrations versus time (linear scale) for treatment with Lovaza® vs. treatment with Epanova® in the 14 day comparative bioavailability study, demonstrating that after 14-days of dosing with a low-fat meal, EPA+DHA levels (AUC₀₋₂₄) from Epanova® were 5.8 fold higher than Lovaza® in subjects maintained on a low-fat diet.

FIG. 14A is a histogram that plots the increases from baseline to steady state in unadjusted blood levels for EPA+DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study, demonstrating that blood levels of EPA+DHA increased 316% from baseline to steady-state in the Epanova® cohort compared to 66% in the Lovaza® cohort. FIG. 14B is a histogram that plots the increases from baseline to steady state in unadjusted C_(avg) for EPA+DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study, demonstrating that average concentration (C_(avg)) levels of EPA+DHA increased 448% from baseline in the Epanova® cohort compared to 90% in the Lovaza® cohort.

FIG. 15A is a histogram that plots the increases from baseline to steady state for total blood levels of DHA in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study, demonstrating that levels of DHA increased 109% from baseline to steady-state in the Epanova® cohort compared to 34% in the Lovaza® cohort. FIG. 15B plots the increases from baseline to steady state for DHA C_(avg) levels in the Epanova® cohort compared to Lovaza® cohort in the 14 day comparative bioavailability study, and demonstrates that average concentration (C_(avg)) levels of DHA increased 157% from baseline in the Epanova® cohort compared to 47% in the Lovaza® cohort.

FIG. 16A is a histogram that plots the increases from baseline to steady state for total EPA levels in blood in the Lovaza® and Epanova® arms of the 14 day comparative bioavailability study, and demonstrates that Levels of EPA increased 1021% from baseline to steady-state in the Epanova® cohort compared to 210% in the Lovaza® cohort. FIG. 16B plots the average concentration increases from baseline to steady-state, and demonstrates that C_(avg) levels of EPA increased 1,465% from baseline in the Epanova® cohort compared to 297% in the Lovaza® cohort.

The data demonstrate that the increase in bioavailability observed after single dosing in the ECLIPSE trial is maintained, even enhanced, over the longer term (2 weeks). In addition, disaggregated subject-specific data (not shown) demonstrate that the subject with least response to Epanova® still had a greater day 14 EPA+DHA C_(max) than the subject with best response to Lovaza®.

The increased C_(avg) and total blood levels of clinically relevant omega-3 PUFA species achieved with Epanova® as compared to Lovaza® predicts significantly improved efficacy in lowering serum triglyceride levels and in reducing cardiovascular risk.

6.9. Example 9: 13 Week Rat Study

This study compared omega-3 exposure and its effects on serum lipid levels in rats treated with equivalent doses of Epanova® or LOVAZA® for 13 weeks.

The Sprague Dawley rat was selected for this study because it was the rat strain used in the toxicology program conducted with Lovaza®, and thus permitted direct comparison of the data from the present study with Epanova® to publicly available rat toxicity data in the Lovaza® Summary Basis of Approval. The study design provided a robust toxicology evaluation of Epanova® with dose selections based upon the publicly available rat toxicity data for Lovaza® (maximum tolerated dose=2000 mg/kg). The Sprague Dawley rats provide a model that is recognized to predict the effects of omega-3 PUFAs on lipid changes for triglycerides and total cholesterol in human subjects. Results at 13 weeks are shown in Table 32, below.

TABLE 32 DHA exposure^(a) EPA exposure^(a) TGs Cholesterol AUC_((0-t)) C_(max) AUC_((0-t)) C_(max) (% difference (% difference Treatment Sex (μg · hr/mL) (μg/mL) (μg · hr/mL) (μg/mL) from control) from control) Epanova ® M 15.56 1.82 14.02 2.15 −32 −45 F 13.00 2.05 9.50 1.38 −53 −41 Both 14.28 1.94 11.76 1.77 −43 −43 Lovaza ® M 6.55 0.47 7.57 0.73 −14 −25 F 4.97 0.40 6.04 0.55 −38 −36 Both 5.76 0.43 6.81 0.64 −26 −31 AUC_((0-t)) Area under plasma concentration time curve to the last sample time. Measure of systemic exposure C_(max) Maximum plasma concentration ^(a)Dose normalized values based on estimated doses of DHA and EPA

As shown in Table 32, Epanova® provided not only markedly higher maximum plasma concentrations (C_(max)) of DHA and EPA than Lovaza®, but also provided markedly higher AUC_((0-t)) for the two omega-3 species; AUC_((0-t)) is a measure of systemic exposure. The greater bioavailability and long term systemic exposure of these two omega-3 PUFA species with Epanova® therapy resulted in long term differences in lipid lowering efficacy, with Epanova® effecting substantially greater reductions in plasma triglycerides and in total cholesterol than was seen with LOVAZA®. The compositions described herein thus provide greater efficacy with respect to two clinically important cardiovascular parameters.

6.10. Example 10: Evolve Trial 6.10.1. Drug Agents

STUDY DRUG (Epanova®)—Type A porcine soft gelatin capsules were prepared, each containing one gram (1 g) of a PUFA composition comprising omega-3 PUFAs in free acid form (“API”). The capsules were coated with Eudragit NE 30-D (Evonik Industries AG). The API had the composition given in batch 2 of Table 10 (see Example 4, above).

PLACEBO—Capsules were prepared containing olive oil for use as a control.

6.10.2. Study Design

A 12-week double-blind, olive oil-controlled, study was performed in the United States, Denmark, Hungary, India, Netherlands, Russia, and Ukraine. Subjects were selected on the basis of high triglyceride levels, in the range of 500-2,000 mg/dL. Subjects were randomly selected to receive 2, 3, or 4 grams of Epanova®, or 4 grams of olive oil as placebo. The general trial design is illustrated in FIG. 17, with FIG. 18 providing a more detailed treatment flow diagram further identifying the timing of study visits. The primary study endpoint was percent change in plasma triglyceride levels from baseline to end-of-treatment (“EOT”). The secondary endpoint was percent change in plasma non-HDL-cholesterol (“Non-HDL-C”) from baseline to EOT.

6.10.3. Results

FIG. 19 shows the disposition of all subjects, with “AE” abbreviating “adverse event” and “SAE” abbreviating “serious adverse event.”

A total of 1,356 subjects were initially screened, and of these, 399 were selected to participate in the study. Of the 399 subjects, 99 received olive oil placebo, 100 received Epanova® 2 g/day; 101 received Epanova® 3 g/day; and 99 received Epanova® 4 g/day. Table 33 shows average triglyceride (TO) and cholesterol measurements for the subjects at randomization (prior to treatment), in comparison to desirable levels as described by the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel produced by the National Heart Lung and Blood Institute.

TABLE 33 Desirable Patients randomized for trial Parameter (mg/dL) ¹ 4 g/day 3 g/day 2 g/day Olive Oil TG <150 655 715 717 686 HDL-C >40 29 28 27 29 LDL-C <100 90 81 77 78 Non-HDL-C <130 225 215 205 215 VLDL-C <30 126 124 123 125 ¹ NCEP ATP III, September 2002

Of the patients receiving olive oil, five total were withdrawn from the study due to the following reasons: withdrawn consent (1), lost to follow-up (1), and other reasons (3). Of the patients receiving Epanova® 2 g/day, seven total were withdrawn due to the following reasons: adverse effects (5), withdrawn consent (1), and other reasons (1). Of the patients receiving Epanova® 3 g/day, 14 total were withdrawn due to: adverse effects (7), noncompliance (2), withdrawn consent (1), lost to follow-up (3), and other reasons (1). Of the patients receiving Epanova® 4 g/day, 9 were withdrawn, due to: adverse effects (5), noncompliance (1), withdrawn consent (2), and other reasons (1).

Epanova® achieved the primary endpoint of triglyceride reduction and the secondary endpoint of reduction of non-HDL cholesterol (total cholesterol level minus the level of HDL-cholesterol) (“non-HDL-C”) at all doses, and produced statistically significant reductions in multiple established markers of atherogenicity: Apo B, Apo CIII, RLP, and LpPLA2. In patients on concomitant statin therapy, Epanova® provided additive efficacy on key lipid parameters: TG; non-HDL-C; HLD-c; total cholesterol (TC); and TC/HDL-C.

Plasma levels of EPA, DHA, and DPA—the three species of omega-3 lc-PUFA in greatest abundance in Epanova®—were measured at baseline and at end-of treatment (EOT), as were plasma levels of the omega-6 lc-PUFA, arachidonic acid (AA). Table 34, below, separately tabulates average baseline, median baseline, average end-of-treatment (EOT), and median EOT plasma levels for EPA, DHA, DPA, and AA, as well as TG, NHDL-C, HDL-C, VLDL-C, and LDL-C.

Baseline plasma levels of EPA, DHA, DPA, and AA indicate effective randomization of subjects among the treatment arms. EPA:AA ratios at baseline were about 0.10 (see Table 37, below).

FIGS. 20A-20E plot the average baseline and end-of-treatment (“EOT”) plasma levels (in μg/mL) for EPA (FIG. 20A), DHA (FIG. 20B), DPA (FIG. 20C) and AA (FIG. 20D), for each of the treatment arms in the EVOLVE trial. FIG. 20E compares average baseline and EOT EPA levels for each treatment arm and the control (olive oil) arm to values earlier reported for ECLIPSE (see Example 7), 14-day bioavailability study (see Example 8), a statin drug-drug-interaction study (Statin DDI), and the unrelated JELIS trial conducted by others with a different omega-3 PUFA formulation (“JELIS”). Note that the Japanese subjects in the JELIS trial had higher baseline EPA levels. FIGS. 21A-21D plot median baseline and end-of-treatment (EOT) plasma levels (in μg/mL) for EPA (FIG. 21A), DHA (FIG. 21B), DPA (FIG. 21C), and AA (FIG. 21D).

TABLE 34 (Baseline and EOT absolute plasma levels) Baseline EOT Baseline EOT (Average) (Average) (Median) (Median) EPA (μg/mL) 2 g 36.6 126.8 26.7 104 3 g 41.4 174.7 30.7 141.9 4 g 38.9 199.7 25.7 170 DHA (μg/mL) 2 g 106.6 159.9 93.5 148.3 3 g 113.7 183.6 97.4 156.9 4 g 104.8 188.8 91.8 169.1 DPA (μg/mL) 2 g 37.6 61.77 35.23 54.59 3 g 38.71 69.36 34.71 58.56 4 g 36.84 69.73 32.53 66.03 AA (μg/mL) 2 g 377.9 327.4 358.4 279.2 3 g 394.9 344 368.8 313.8 4 g 393.9 298.1 363.4 274.2 TG (mg/dL) 2 g 760.1 608.7 669 554 3 g 766.9 754.5 612 560.8 4 g 730.5 557.2 631 511 Non-HDL-C 2 g 219.6 208.2 205.3 209.3 (mg/dL) 3 g 223.4 221.5 215.3 197 4 g 230.7 214.1 225 211 HDL-C 2 g 28 30.7 27.3 29 (mg/dL) 3 g 29.1 30.4 28 28 4 g 29.9 32.2 28.7 29 V-LDL-C 2 g 138.1 106.9 123.3 98 (mg/dL) 3 g 143 121.5 124 93.8 4 g 143.9 100.7 126 87 LDL-C 2 g 83.1 101.3 77.3 93.3 (mg/dL) 3 g 84.9 99.7 81 95 4 g 90.4 113.4 90.3 109.5 ApoB (mg/dL) 2 g 115.6 121.1 114 120 3 g 114.5 116 112 115 4 g 119.3 126.6 118 121.5 ApoCIII 2 g 26.5 24.3 22 21 (mg/dL) 3 g 27.8 25 27 21 4 g 27.5 22.7 27 21 RLP (mg/dL) 2 g 55.5 49.7 49.7 37 3 g 62.7 54.4 54.4 34.5 4 g 58.1 43.4 43.4 33 LpPLA2 2 g 270.6 236.7 266 225 (ng/mL) 3 g 271.2 241.4 244.5 223.5 4 g 266.9 223.2 249 208

Table 35, below, tabulates the average change and the median change in absolute plasma levels from baseline to EOT for EPA, DHA, DPA, and AA, as well as TG, NHDL-C, HDL-C, VLDL-C, and LDL-C.

TABLE 35 AA EPA DPA DHA TG non-HDL-C HDL-C VLDL-C LDL-C (μg/mL) (μg/mL) (μg/mL) (μg/mL) (mg/dL) (mg/dL) (mg/dL) (mg/dL) (mg/dL) average change from baseline to EOT 2 g −50.5 90.2 24.17 53.3 −183.6 −13.3 2.6 −31.2 18 3 g −50.9 133.3 30.65 69.9 −69 −6.1 1.7 −21.9 15.5 4 g −95.8 160.8 32.89 84 −220.2 −21.9 2.1 −42.5 21.7 median change from baseline to EOT 2 g −79.2 77.3 19.36 54.8 −172.2 −16 1.7 −31.5 14.8 3 g −55 111.2 23.85 59.5 −150.1 −6.7 1.8 −25.3 11.9 4 g −89.2 144.3 33.5 77.3 −178 −17 1.7 −37.7 22.3

FIGS. 22A, 22B, 26A, and 26B plot the data in the table above, showing the change from baseline to EOT in absolute plasma levels (in μg/mL) of AA, DHA, EPA, and DPA for each of the treatment arms of the EVOLVE trial, with FIG. 22A plotting average change and FIG. 22B showing median change from baseline.

Table 36A, below, separately tabulates average, median, and least squares mean percentage change from baseline to EOT in plasma levels of EPA, DHA, DPA, and AA, as well as TG, NHDL-C, HDL-C, VLDL-C, and LDL-C, for each of the treatment arms of the EVOLVE trial.

Table 36B, below, separately tabulates average, median, and least squares mean percentage change from baseline to EOT in plasma levels of ApoB, ApoCIII, LpPLA2, and RLP, for each of the treatment arms of the EVOLVE trial.

TABLE 36A AA EPA DPA DHA TG n-HDL-C HDL-C VLDL-C LDL-C (μg/mL) (μg/mL) (μg/mL) (μg/mL) (mg/dL) (mg/dL) (mg/dL) (mg/dL) (mg/dL) average percentage change from baseline to EOT 2 g −10.5 410.8 86.08 69 −21.2 −5.4 10 −21.2 25.6 3 g −11.2 538.1 96.59 88.4 −14.1 −3.4 5.6 −18.6 20 4 g −18 778.3 131.66 106 −25.2 −8 7.2 −27.5 26.2 median percentage change from baseline to EOT 2 g −15.6 253.9 75.3 61.2 −25.8 −7.7 7 −24.7 21.4 3 g −17.9 317 68.6 61.9 −21.7 −3.2 6.2 −21.5 15.5 4 g −25.9 404.8 74.87 65.5 −30.7 −7.7 5 −34.7 26.2 LS mean percentage change 2 g −15.14 267.04 — 56.72 −26.47 −7.77 7.46 −27.05 19.35 3 g −15.98 331.86 — 64.07 −24.38 −6.49 3.33 −25.62 13.94 4 g −23.2 406.32 — 71.77 −31.1 −9.76 5.71 −33.23 19.36

TABLE 36B ApoB ApoCIII LpPLA2 RLP average percentage change from baseline to EOT 2 g 5.9 −8.3 −11.3 −0.9 3 g 4.6 −8.5 −8.8 −6.9 4 g 5.7 −9.8 −14.1 −10.3 median percentage change from baseline to EOT 2 g 6.3 −8.7 −11.3 −20.2 3 g 5.6 −12.8 −9.5 −16.2 4 g 5.7 −15 −14.6 −28.2 LS mean change (%) 2 g 3.84 −10.87 −14.93 −20.67 3 g 2.28 −12.16 −11.06 −22.63 4 g 3.78 −14.39 −17.17 −27.52

FIG. 23A plots the average change from baseline to EOT, as percentage of baseline value, for AA, DHA, EPA, and DPA in each of the treatment arms of the EVOLVE trial, and FIG. 23B plots the median percent change from baseline to EOT.

Table 37 below presents EPA/AA ratios at beginning and end-of-treatment for each of the treatment arms of the EVOLVE trial.

TABLE 37 EPA/AA ratios baseline EOT average 2 g 0.096851 0.387294 3 g 0.104837 0.507849 4 g 0.098756 0.669909 median 2 g 0.074498 0.372493 3 g 0.083243 0.452199 4 g 0.070721 0.619985

As can be seen from Tables 35 and 36A and FIGS. 20-23, 12 week treatment with Epanova® caused dramatic increases in plasma levels of EPA, DHA, and DPA. For example, at the 2 g dose, the average percentage change from baseline to EOT in EPA plasma levels was 411%; at the 4 g dose, 778%. Median percentage change in EPA plasma levels were respectively 254% and 405%. At the 2 g dose, the average percentage change from baseline to EOT in DHA plasma levels was 69%; at the 4 g dose, the average percentage change was 106%. Median percentage change in DHA plasma levels appear less dramatic, with a 61.2% change at 2 g Epanova®, and 65.5% change at 4 g.

Increases in plasma levels of EPA, DHA, and DPA were accompanied by significant reductions in plasma AA levels, with the 4 g dosage regimen effecting an average reduction of 95.8 μg/mL and median reduction of 89.2 μg/mL, which correspond to an average percentage reduction of 18%, a median percentage change of 25.9%, and a LS mean change of 23.2%. It should be noted that the decrease in plasma arachidonic acid levels was observed despite exogenous administration of arachidonic acid, which was present at 2.446% (a/a) in the Epanova® batch used in this trial.

The increase in EPA plasma levels and concomitant reduction in AA plasma levels cause a significant improvement in the EPA/AA ratio, as shown in Table 37, from approximately 0.10 at baseline to approximately 0.67 (average) and 0.62 (median) at EOT at the 4 g dose.

Furthermore, treatment with Epanova® resulted in substantial reductions in TG levels, as shown in FIG. 26A and FIG. 26B which plot the average and median, respectively, for the absolute change from baseline. FIG. 27 illustrates the percentage of subjects who exhibited 0-10% reduction in TG, 10-20% reduction in TG, 20-30% reduction in TG, 30-40% reduction in TG, 40-50% reduction in TG, and greater than 50% reduction in TG, for Epanova® 2 g and 4 g doses.

FIG. 26A and FIG. 26B also show that non-HDL-C and VLDL-C were reduced, while HDL-C was elevated. LDL-C levels were also elevated, a measurement that is likely due to an increase in LDL particle size upon treatment (discussed further in Example 12). Average and median percentage changes are displayed in FIG. 28A and FIG. 28B, respectively.

Absolute average baseline and EOT levels are plotted in FIGS. 24A-24I for TG (FIG. 24A), Non-HDL-C (FIG. 24B), HDL-C (FIG. 24C), V-LDL-C (FIG. 24D), LDL-C (FIG. 24E), ApoB (FIG. 24F), ApoCIII (FIG. 24G), RLP (FIG. 24H), and LpPLA2 (FIG. 24I). Absolute median baseline and EOT levels are plotted in FIGS. 25A-25I for TG (FIG. 25A), Non-HDL-C (FIG. 25B), HDL-C (FIG. 25C), V-LDL-C (FIG. 25D), LDL-C (FIG. 25E), ApoB (FIG. 25F), ApoCIII (FIG. 25G), RLP (FIG. 25H), and LpPLA2 (FIG. 25I).

The extremely high bioavailability of the omega-3 PUFAs in Epanova® revealed differences in pharmacokinetic response among the various plasma species. FIG. 29 plots the rate of change in the median percentage change from baseline in plasma levels of EPA, DHA, DPA, AA, TG, non-HDL-C, and HDL-C (absolute value) between 2 g and 4 g doses of Epanova®. Table 38, below, tabulates the results:

TABLE 38 (rate of change in median percentage change from baseline) (absolute value) EPA DHA DPA AA TG non-HDL-C HDL-C 0.59432847 0.07026143 0.00571049 0.66025641 0.189922 0 0.285714

Given little or no increase in plasma levels of DHA and DPA upon doubling of the Epanova® dose from 2 g to 4 g per day, the rate of change (slope) in the median percentage change from baseline is near zero, predicting little further increase in DHA and DPA plasma levels will be seen upon further increase in dose. Similar plateauing of response is seen in triglyceride levels, HDL-C levels, and non-HDL-C levels (data not shown).

By contrast, the rate of change for EPA remains high, with a slope of 0.59; further increase in EPA plasma levels is expected to be obtained by increasing Epanova® dosage above 4 g/day. Significantly, the rate of change in AA levels upon doubling the Epanova® dose from 2 g to 4 g per day is even higher than that for EPA; further reductions in AA plasma levels are expected as Epanova® dosage is increased above 4 g/day. Epanova® thus exhibits unprecedented potency in ability to reduce AA levels.

Summary of the results of the EVOLVE trial are tabulated in Table 39, below.

TABLE 39 2 gram (n = 99) 3 gram (n = 97) OO (n = 98) LSM LSM 4 gram (n = 99) Baseline Baseline p- difference Baseline difference Baseline LSM (mg/dL) % A (mg/dL) % A value rel. to OO (mg/dL) % A p-value rel. to OO (mg/dL) % A p-value difference TG 686.3 −10.4 717 −25.8 0.003 −22.1 715 −21.7 0.021 −20 655 −30.7 <0.001 −26.7 Non- 214.5 −0.9 205.3 −7.7 0.018 −10.3 215.3 −3.2 0.042 −9 225 −7.7 0.002 −12.2 HDL-C HDL-C 28.7 2.2 27.3 7 0.088 5.5 28 6.2 0.127 1.4 28.7 5 0.127 3.7 TC/ 8.8 −1.9 8.8 −9.5 0.024 −11.8 8.8 −7.2 0.137 −7.7 9 −14.1 0.004 −12.9 HDL-C LDL-C 78.2 9.8 77.3 21.4 0.003 16.2 81 15.5 0.092 10.8 90.3 26.2 <0.001 16.3 VLDL-C 124.5 −11.3 123.3 −24.7 0.006 −18.4 124 −21.5 0.017 −17 126 −34.7 <0.001 −24.6 ApoB 110 2.3 114 6.3 0.344 3 112 5.6 0.834 1.4 118 5.7 0.449 2.9

The EVOLVE trial also demonstrated that Apolipoprotein CIII (ApoCIII) was significantly reduced by Epanova® treatment. ApoCIII inhibits lipoprotein lipase activity and hepatic uptake of triglyceride-rich lipoproteins. Elevated levels of ApoCIII have been found to be an independent predictor for cardiovascular heart disease (CHD) risk while genetically reduced ApoCIII is associated with protection from CHD.

Omega-3 fatty acid formulations containing DHA have been shown to increase LDL-C in patients with severe hypertriglyceridemia (Kelley et al., 2009, J. Nutrition, 139(3):495-501). This effect on LDL-C is postulated to be a result of increased lipoprotein particle size (Davidson et al., 2009, J. Clin. Lipidology, 3(5):332-340). Clinical data suggest that eicosapentaenoic acid (EPA) alone, at a dose which lowers triglycerides to a similar extent as EPA+DHA, does not raise LDL-C, but also fails to lower ApoCIII (Homma et al., 1991, Atherosclerosis, 91(1):145-153).

FIG. 34 shows the correlation between percent change in LDL and percent change in ApoCIII for data from the EVOLVE trial. A Pearson correlation coefficient of −0.28 was obtained when these data were fit using a linear regression, demonstrating that increases in LDL correlated with decreases in ApoCIII upon treatment with Epanova®. These results are consistent with previous reports of increased LDL upon administration of DHA, an observation that may be attributed to increased lipoprotein particle size. The effects of Epanova® on lipoprotein particle size are discussed further in Example 12, below.

A subset of subjects, shown in Table 40, exhibited a greater than 800% increase in EPA with less than 5% decrease in triglyceride levels. This failure to respond can likely be attributed to a deficiency or functional defect in the Type 1 lipoprotein lipase (LPL) enzyme. LPL hydrolyzes triglycerides present in chylomicrons to free fatty acids, and impairment of LPL is known to be associated with severe hypertriglyceridemia (Fojo and Brewer, 1992, J. of Int. Med. 231:669-677). Subjects who exhibit a substantial increase in EPA following treatment with Epanova®, accompanied by a minor change in clinical parameters such as triglyceride levels, AA levels, etc., can be classified as non-responders. Such subjects can be removed from treatment with Epanova®.

TABLE 40 TG % EPA % EOT change BASELINE EOT change COUNTRY BASELINE TG from EPA EPA from Baseline of the subject Dose BMI TG (mg/dL) (mg/dL) baseline (mcg/mL) (mcg/mL) baseline HbA1c EOT HbA1c Hungary 2 32.4 778 831 6.8 18.4 171.4 832 7.3 8.1 Hungary 2 33.4 924 937 1.4 11.4 133.6 1067 5.9 6.2 Hungary 2 36.2 782 803 2.6 12.5 173.6 1288 6.0 5.6 Russia 2 31.2 857 1723 101.1 22.1 243.7 1001 5.6 6.2 Netherlands 2 27.1 511 589 15.2 15.4 257.4 1572 5.0 5.0 India 2 25.1 460 544 18.4 4.6 79.9 1632 6.7 6.6 US 3 34.6 1047 1077 2.8 16.7 273.7 1543 6 5.6 US 3 36 622 687 10.3 16.4 193.8 1080 6.6 7.2 US 3 31 838 870 3.8 14.3 151.2 961 5.6 6.1 US 3 40.8 888 995 12 61.8 650.6 953 8 8.7 Hungary 3 36.3 484 463 −4.3 10.1 185.3 1740 6.1 6.0 Hungary 3 29.6 647 627 −3.1 8.6 110.3 1177 6.2 6.3 Hungary 3 36.6 851 1016 19.3 10.4 94.4 811 8.2 8.6 Hungary 3 28.6 707 730 3.2 8.3 408.5 4827 5.8 6 Hungary 3 32.8 2158 2273 5.3 24.5 480.1 1863 5.6 5.1 Hungary 3 31.7 1034 992 −4.1 10.6 280.5 2538 5.3 5.5 Hungary 3 34.8 976 1110 13.7 22.4 224.8 905 7.3 7.9 Hungary 3 28.8 728 1210 66.1 22.4 289 1071 7.1 7.9 Ukraine 3 36.2 1664 10317 520.1 91.9 1238.8 1248 8.1 10.8 Hungary 4 30.1 714 702 −1.7 11.1 256.7 2214 5.1 5.4 Hungary 4 31.7 785 1300 65.6 11.7 466 3886 8.5 10.9 Hungary 4 27.3 513 527 2.6 16.6 198.3 1093 7.8 8 Hungary 4 31.9 508 625 23.2 3.5 198.4 5504 6 7.3 Ukraine 4 33.6 563 589 −2.5 34.9 327.9 841 7 7.3 Russia 4 29.7 664 702 5.7 38.2 795.2 1984 5.5 5.1 Russia 4 41.6 483 504 4.3 10.9 231.1 2026 6.2 6.3 India 4 32.8 839 1721 105.0 13.8 1066.6 7624 5.6 5.2

6.11. Example 11: Statin Drug-Drug Interaction Trial 6.11.1. Drug Agents

STUDY DRUG (Epanova®)—Type A porcine soft gelatin capsules were prepared, each containing one gram (1 g) of a PUFA composition comprising omega-3 PUFAs in free acid form (“API”). The capsules were coated with Eudragit NE 30-D (Evonik Industries AG). The API had the composition given in batch 3 of Table 9 (see Example 4, above).

STUDY DRUG (Zocor®)—40 mg tablets of simvastatin produced by Merck Sharp & Dohme Ltd. were obtained from a commercial source.

STUDY DRUG (Aspirin®)—81 mg enteric-coated tablets produced by Bayer HealthCare Pharmaceuticals were obtained from a commercial source.

6.11.2. Study Design

An open-label, randomized, 2-way crossover study was designed to evaluate the effect of multiple doses of Epanova® on the multiple-dose pharmacokinetics of simvastatin in healthy normal subjects. Low dose aspirin (81 mg) was also be administered daily in both study arms.

Treatment condition “A” consisted of co-administration of an oral dose of 40 mg of simvastatin (1 tablet), 81 mg of aspirin (1 tablet) and 4 g (4 capsules) of Epanova®, once a day (every 24 hours) with 240 mL of water on the mornings of Days 1 to 14, for a total of 14 doses, under fasting conditions. Treatment condition “B” consisted of administration of an oral dose of 40 mg of simvastatin (1 tablet) and 81 mg of aspirin (1 tablet) once a day (every 24 hours) with 240 mL of water on the mornings of Days 1 to 14, for a total of 14 doses, under fasting conditions. There was a 14 day washout between treatments.

A total of 52 subjects were enrolled and randomized with respect to order of treatment. Of these, 46 participants were Hispanic.

Blood was drawn for plasma fatty acid levels (EPA, DHA, AA) at check-in (day −1) and at check-out (day 15) following the treatment arm with Epanova® (treatment “A”). Genotyping was performed at various previously identified SNPs, including SNPs in the FADS1 gene (e.g. rs174546), including a SNP associated with conversion of DGLA to AA (SNP rs174537), the FADS2 gene, and Scd-1 gene.

6.11.3. Results

Average baseline and end-of-treatment (“EOT”) plasma levels (in μg/mL) for EPA levels are shown in FIG. 20E.

FIG. 56 shows arachidonic acid (AA) plasma levels for subjects grouped according to genotype at the rs174546 SNP, at (A) baseline (in μg/mL), and (B) day 15 of treatment with Epanova® (in percent change from baseline). For each genotype, the interquartile range is indicated by a box, the median is indicated by a horizontal line in the interior of the interquartile box, and the mean is represented by a diamond. Outliers are represented by open circles. The whiskers extend to the minimum and maximum non-outlier value. Score 1 identifies subjects who are homozygous at the major allele; Score 3 identifies subjects homozygous at the minor allele; and Score 2 represents heterozygotes.

Prior to treatment, the Hispanic population had a higher prevalence of TT homozygotes (41%) compared to CC homozygotes (24%) for SNP rs174546. This corresponded to significantly different baseline levels of EPA (CC=18 μg/mL; CT=11 μg/mL; TT=7 μg/mL, p<0.0001) and arachidonic acid (AA) (CC=266 μg/mL; CT=202 μg/mL; TT=167 p<0.0001) across genotypes.

In response to treatment with Epanova®, a substantial increase in EPA was observed, with the largest percent increase in the TT genotype (TT: 1054%, CT: 573%, CC: 253%).

6.12. Example 12: ESPRIT Trial 6.12.1. Drug Agents

STUDY DRUG (Epanova®)—Type A porcine soft gelatin capsules were prepared, each containing one gram (1 g) of a PUFA composition comprising omega-3 PUFAs in free acid form (“API”). The capsules were coated with Eudragit NE 30-D (Evonik Industries AG). The API had the composition given in batch 3 of Table 9 (see Example 4, above).

PLACEBO—Capsules were prepared containing olive oil for use as a control.

6.12.2. Study Design

As shown in FIG. 38, a subset of subjects in the 2 g treatment arm of the EVOLVE trial who were receiving concurrent statin therapy displayed greater magnitudes of percentage changes (mean LS difference), relative to control, for TG, non-HDL-C, HDL-C, LDL-C, TC, VLDL-C, and TC/HDL-C, when compared to those subjects in the 2 g treatment arm who did not receive concurrent statin therapy. Subjects receiving concurrent statin therapy showed a dose-dependent response to Epanova®, as shown in comparative data for Epanova® 2 g and Epanova® 4 g displayed in FIG. 39.

As a follow-on to the enhanced efficacy observed for Epanova® in conjunction with statin therapy, the ESPRIT clinical trial was conducted to study patients on baseline statin therapy. As shown in FIG. 40, patients were selected for the ESPRIT study based on TG levels between 200-500 mg/dL and baseline statin therapy. Of the 660 patients who were selected for the trial, 220 were treated with olive oil placebo, 220 were treated with Epanova® 2 g dose, and 220 were treated with Epanova® 4 g dose. All placebo and Epanova® treatments were administered in addition to the baseline statin therapy.

Table 41, below, shows the baseline levels for TG, HDL-C, LDL-C, non-HDL-C, and VLDL-C for subjects in the ESPRIT trial, in comparison to desirable levels as described by the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), issued by the National Heart Lung and Blood Institute.

TABLE 41 Baseline levels Desirable (mg/dL) 2 g/day 4 g/day Olive Oil (OO) TG <150 265 265 269 HDL-C >40 38 37 38 LDL-C <100 92 91 87 Non-HDL-C <130 139 135 132 VLDL-C <30 42 43 42

6.12.3. Results

FIG. 41 illustrates the patient disposition for the ESPRIT trial, showing that 6 patients were withdrawn from the placebo arm, 6 patients were withdrawn from the 2 g treatment arm, and 12 patients were withdrawn from the 4 g treatment arm. The number of patients who experienced adverse effects (AE) was low overall, with 2 in the placebo arm, 3 in the 2 g treatment arm, and 7 in the 4 g treatment arm.

Patients in the ESPRIT trial exhibited significant percentage changes in plasma EPA and DHA levels, as shown in FIG. 42A and FIG. 42B, respectively. These patients also demonstrated dose-dependent reductions in TG, reductions in non-HDL-C, and increases in HDL-C, compared to olive oil placebo (see FIG. 43). Furthermore, dose-dependent reductions in VLDL-C and TC/HDL-C were observed (see FIG. 44). Taken together, the results of FIGS. 42-44 demonstrate efficacy of Epanova® as an add-on to statin therapy.

Further details of the results of the ESPRIT trial are presented in FIGS. 45-52, demonstrating that Epanova® is efficacious as an add-on to both low-potency and high-potency statins, in a range of baseline patient conditions. FIG. 45 shows the results for median TG percentage change from baseline for three tertiles of patients, partitioned by baseline TG levels. FIG. 46 shows the results for median non-HDL-C percentage change from baseline for three tertiles of patients, partitioned by baseline non-HDL-C levels. FIG. 47 shows the results for median LDL-C percentage change from baseline for three tertiles of patients, partitioned by baseline LDL-C levels.

As seen from FIG. 48, the reductions in TG levels were observed for patients who received concurrent rosuvastatin, atorvastatin, and simvastatin therapy. Statistically significant effects on triglycerides, non-HDL-C, and LDL-C levels were observed regardless of whether low potency or high potency statins were co-administered, as shown in FIGS. 49-51.

FIG. 52 compares median percentage changes from baseline for triglycerides for (A) patients having higher TG baseline levels (≥294 mg/dL), (B) patients having high baseline EPA levels (≥26.58 μg/mL), and (C) patients receiving concurrent rosuvastatin therapy. The results show that the Epanova® 2 g dose works similarly to the 4 g dose in those patient populations shown in FIG. 52.

The increased LDL-C levels observed upon treatment with Epanova® were consistent with observed increased lipoprotein particle size. Large VLDL, medium VLDL, small VLDL, VLDL total, and VLDL size were measured for placebo and each of the treatment arms of the ESPRIT trial. The results are displayed in FIG. 53 and show that Epanova® treatment resulted in decreased amounts of large VLDL particles and correspondingly increased amounts of small VLDL particles. Decreased VLDL particle size was observed, as shown in FIG. 53, together with increases in LDL particle size, as shown in FIG. 54. Shown in FIG. 55, as end-of-treatment TG levels decreased, percentage increases in LDL-P size were larger. Taken together, FIGS. 53-55 demonstrate that Epanova® treatment resulted in increased lipoprotein particle size, an observation that can account for the observed increased LDL-C.

Table 42, below, summarizes the results of the ESPRIT trial.

TABLE 42 Olive Oil (OO) 4 g/day* 2 g/day* Base EOT %Δ Base EOT %Δ p-value diff Base EOT %Δ p-value diff Non- median 132 134 1 135 129 −6 <0.001 −6 139 133 −3 0.037 −3 HDL-C mean 135 136 1 139 132 −5 140 136 −2 TG median 269 260 −4 265 215 −21 <0.001 −15 265 222 −15 <0.001 −9 mean 280 268 −3 287 233 −18 284 244 −14 HDL-C median 38 38 2 37 38 3 0.988 1 38 39 2 0.988 0 mean 39 40 3 39 40 4 39 40 3 LDL-C median 87 91 2 91 92 1 0.647 0 92 95 5 0.025 4 mean 92 93 4 94 94 4 92 97 6 VLDL-C median 42 41 −3 43 33 −20 <0.001 −16 42 37 −12 0.008 −8 mean 46 44 3 47 38 −14 47 40 −10 TC median 174 174 1 170 167 −4 <0.001 −4 177 174 −1 0.049 −2 mean 174 176 1 178 172 −3 179 176 −1 TC/ median 5 5 −2 5 4 −7 0.001 −5 5 5 −4 0.119 −3 HDL-C mean 5 5 −1 5 5 −6 5 5 −3

All publications, patents, patent applications and other documents cited in this application are hereby incorporated by reference in their entireties for all purposes to the same extent as if each individual publication, patent, patent application or other document were individually indicated to be incorporated by reference for all purposes.

While various specific embodiments have been illustrated and described, it will be appreciated that various changes can be made without departing from the spirit and scope of the invention(s). 

What is claimed is:
 1. A method of treating hypertriglyceridemia, comprising orally administering to a patient having pre-treatment serum or plasma triglyceride levels of about 200 mg/dL to about 500 mg/dL a therapeutically effective amount of a pharmaceutical composition comprising: eicosapentaenoic acid (EPA), in an amount of 50% to 60% by weight; docosahexaenoic acid (DHA), in an amount of 17% to 23% by weight; and docosapentaenoic acid (C22:5 n-3) (DPA), in an amount of 1% to 8% by weight; wherein at least 90% by weight of the polyunsaturated fatty acid in the composition is present in the free acid form; and wherein the composition is not administered at the same time as a statin.
 2. The method of claim 1, wherein at least 95% by weight of the polyunsaturated fatty acid in the composition is present in the free acid form.
 3. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 1.5%.
 4. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 2%.
 5. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 2.5%.
 6. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 3%.
 7. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 3.5%.
 8. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 4%.
 9. The method of claim 1, wherein DPA is present in the composition in a weight percent amount of at least 4.5%.
 10. The method of claim 1, wherein the composition comprises a unit dose of at least 500 mg of the composition.
 11. The method of claim 1, wherein the composition comprises a unit dose of about 1 gram of the composition.
 12. The method of claim 1, comprising orally administering a dose of 2-4 grams per day of the composition.
 13. The method of claim 12, wherein the dose is 2 grams per day.
 14. The method of claim 1, further comprising orally administering to the patient a therapeutically effective amount of rosuvastatin, wherein the composition is not administered at the same time as the rosuvastatin.
 15. The method of claim 1, wherein the patient is concurrently on statin therapy.
 16. The method of claim 15, wherein the statin is selected from pravastatin, lovastatin, simvastatin, atorvastatin, fluvastatin, rosuvastatin, tenivastatin, and pitavastatin.
 17. The method of claim 15, wherein the statin is rosuvastatin.
 18. The method of claim 1, comprising administering the composition for a duration effective to reduce serum or plasma triglycerides by at least about 5% below pre-treatment levels.
 19. The method of claim 1, comprising administering the composition for a duration effective to reduce serum or plasma triglycerides by at least about 10% below pre-treatment levels.
 20. The method of claim 12, wherein the dose is 4 grams per day.
 21. A method of treating hypertriglyceridemia, comprising orally administering to a patient having pre-treatment serum or plasma triglyceride levels of about 200 mg/dL to about 500 mg/dL a therapeutically effective amount of a pharmaceutical composition and a therapeutically effective amount of a statin; wherein the pharmaceutical composition comprises: eicosapentaenoic acid (EPA), in an amount of 50% to 60% by weight; docosahexaenoic acid (DHA), in an amount of 17% to 23% by weight; and docosapentaenoic acid (C22:5 n-3) (DPA), in an amount of 1% to 8% by weight; wherein at least 90% by weight of the polyunsaturated fatty acid in the composition is present in the free acid form; the statin is administered on a dosage schedule different from the pharmaceutical composition; and the method comprises administering a single statin.
 22. The method of claim 21, wherein the statin is selected from pravastatin, lovastatin, simvastatin, atorvastatin, fluvastatin, rosuvastatin, tenivastatin, and pitavastatin.
 23. The method of claim 21, wherein the statin is rosuvastatin.
 24. The method of claim 21, wherein the composition is not administered at the same time as a statin.
 25. The method of claim 21, wherein at least 95% by weight of the polyunsaturated fatty acid in the composition is present in the free acid form.
 26. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 1.5%.
 27. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 2%.
 28. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 2.5%.
 29. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 3%.
 30. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 3.5%.
 31. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 4%.
 32. The method of claim 21, wherein DPA is present in the composition in a weight percent amount of at least 4.5%.
 33. The method of claim 21, wherein the composition comprises a unit dose of at least 500 mg of the composition.
 34. The method of claim 21, wherein the composition comprises a unit dose of about 1 gram of the composition.
 35. The method of claim 21, comprising orally administering a dose of 2-4 grams per day of the composition.
 36. The method of claim 35, wherein the dose is 2 grams per day.
 37. The method of claim 35, wherein the dose is 4 grams per day.
 38. The method of claim 21, comprising administering the composition for a duration effective to reduce serum or plasma triglycerides by at least about 5% below pre-treatment levels.
 39. The method of claim 21, comprising administering the composition for a duration effective to reduce serum or plasma triglycerides by at least about 10% below pre-treatment levels.
 40. A method of treating hypertriglyceridemia, comprising orally administering to a patient having pre-treatment serum or plasma triglyceride levels of about 200 mg/dL to about 500 mg/dL a therapeutically effective amount of a pharmaceutical composition comprising polyunsaturated fatty acids as the sole active pharmaceutical ingredient; wherein at least 90% by weight of the polyunsaturated fatty acid in the composition is present in the free acid form; and the polyunsaturated fatty acids comprise: eicosapentaenoic acid (EPA), in an amount of 50% to 60% by weight of the composition; docosahexaenoic acid (DHA), in an amount of 17% to 23% by weight of the composition; and docosapentaenoic acid (C22:5 n-3) (DPA), in an amount of 1% to 8% by weight of the composition.
 41. The method of claim 40, wherein the polyunsaturated fatty acids further comprise: heneicosapentaenoic acid (C21:5 n-3); arachidonic acid (C20:4 n-6) (AA); eicosatetraenoic acid (C20:4 n-3); moroctic acid (C18:4 n-3); docosapentaenoic acid (C22:5 n-6); and linoleic acid (C18:2 n-6).
 42. The method of claim 40, wherein the patient is concurrently on statin therapy with a statin selected from pravastatin, lovastatin, simvastatin, atorvastatin, fluvastatin, rosuvastatin, tenivastatin, and pitavastatin.
 43. The method of claim 40, wherein the patient is concurrently on statin therapy with rosuvastatin. 